23739 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project id77(i,,7t7------7 PERMIT NO.
Building Address: 23739
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Tera A
� �,,,, CITY OF CUPERTINO-BUILDING DMS O
Con eNamc: Ec.No: -APPLICATION /PERMIT L
qPArchitect/Engines LIc.No: BUILDING-ELECTRICA4PLUMBING HAM L CATEGORY CO
;+, BUILDING RMLT IN FO ,I�ELECTRICPER i11
n
. '.'FLT' .
Address: _ _ PFRMITISSUANCE � � , f�N,
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that lam Bcenaed underprovlslone of Cha pter9(rommenc APPLIA J DESCRp'fl y
In W.isithI41on force and offlon3°(the Buslnessand Profeselona Code,and myor
license lsinfull fora and effect. ANELS 6ri•- Is�II//�/a�T
License Class Lmur R
Date Contractor
ARCHITECTS DECLARATION 201-1000 A.
pZ I understand my plans shall be used as public records. OVER]fNXI Q.FT.FLOG FA f/SQoLicensed Professional SIGNS ELECTRICAL �OWNER-BUILDER DECLARATION q psT
H y SPEGIALCIRCUIT/M
Ihereb ..a.affirrathatlam exemptfromthe Cont Tactors License law(m the /' O l
zp following reason.(Section 7031.5,Busine®and Professions Code:Any tlty or (Colo
�OyF: 7EMP.METPR OR POLE ®oo i Li L
P5 countywhkh aqulma perMttoroo requires the
apmvgdemsuch,or repair
any asractumsigned pdorm its Lha the i,alsoaquiaatuant to
for
rdsuch paf the ROWER DEVICES
file a signed statement that he V licensed pursuant to the proWlova of the 1 L/ys
I OI eo Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi. SWIMMING POOL ELE 1 W
EO� elon3o(the Buslnessand Professions Code)orthathele exempt lhercfromand 'VALUATION
�^ the basis for the alleged exemption. Any violation menalty o rdi m by any
applicant for apermit alleed jeds the exemption,
licant Any
oa ion penalty not .5 by any
OITILETSSWI7CHES E5
five hundred dollars(5500).
NEW RFS[DF3 R7 ELECIR ,FI'.
'6 �I,as owner of the property,or my employees with wages't creole _ STORIES TYPE CONSTRUCTION
comN
pensatlon,willdoe work mat
and thestrm b not inteaded, offeredfco + �1 1
O sale(Sec.7614,Business and Professlmrs Code:The Contractmfe Llceme law rL�
�$ does not apply loan owner of property who Wilds or improves thereon,and OCC.GROUP RFS.UNITS
.who docssuch work himself orthrough his own employees,provided that such
improvements are not Intended mof(ered forsale.If,however,the W ilding or
Improvement bsoid within oneyearofcompleian,the°wner-bullderwlll have '
C.:
ofpm"off that he did not Wild or lmprove for purposeo(ule.). QTY, PLUMBING PERMIT FEET" FLOG ZOD AAPN.
as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
tto toroostroct the project(Sec.70K Buelness sner of property who odPro(esslors Code: -
e Communes License Law does not apply to an owALTER-DRAIN&VENT- ATTR(FA)
Wild•or Improves thereon, and who contracts for such pRu)ect,with a ` FEE SUMMARY ,s
c��LLI{{a'ctors)licensed pursuant to the Contractors License Law. BACK}7AWPA .D CE
IJ I am exempt un er Sec B&P C for this reason
a SANITARY V N
Owner ate DRAINS- F, ,GOND. RECE91T
ORKM O P A ION [CLARATI Nelf-ErtFIXTURES PER TRA SCHOOL TAX Y N
cedif❑I hereby orken that I have a l rt cone of a mnift d pythemofurs,ora RECEIPT N
3800,Lab of Work,rs'Compevallonlmuance oracerti(led copythemof(Sec. GAS EA.SYSTEM-]INCA TS
3800,lois C.)' PARK FEE - Y N
Pol
Com an GAS.EA.SYSTIM-OVER4 DING DIIPT x
MY BUILDING DI INFF.ES 1
Certl(kd copy is,herebyte city
MCcrtl(led copy6 filed withh the cairy -inspection division. CREASE/INDUSERL WASTE INTFRC To , PLANCHE CE
_
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASF.7RAI'
COMPENSATION INSURANCE P SEWER-SANITARY-STORM EA.20EFf. I Date RCCei l f�Q
(Thlssection need not be completed if the permit is forma,hundred dollars
(f106)orless.) - WATER HEATERW/VENT • ENERGYFEE Y
(certify that[.the per(mrmana of the work Icor whkhthio /ELECTR
permit le issued,
I shall not employ any person In any manner eo as to become subject to the WATER SYSTEM/TREATING L. ✓ ��
Workers Compensation Laws of California:Date PAID
0 Z - Applicant Date R cel t#
I'ZD NOTICE TO APPLICANT:If,a her making this Certificate of Exemption,you NEW REMDENTIAL PLM& SQrL
Ir N should become sublet to the Workers'Comperuatlon Provisions,of the Labor T AL:
Code,you must(orthwith comply with such provlslom or this permit shall be ems
j deemed revoked.
1 W C CONSTRUCTION LENDING AGENCY SEISMIC F _
a Ihereby affirm that there is a construction lending agency for the perform-
Z0
erform ELECT
ZO arm of the work for which this permit is is sued(Sec.3097,ON.C.) PLU N FE
(') lender'a Name -
LL I— Larder's Address QTY'. �';MiCHANICAL,PERMIT ,FEE ', MCI-IA ICA FEE
O W ImAifythatlhavemadthsappliationandtlatethattheabovelnformation
bconect.I agreeto comply with all city and county ordinances and state laws PERMITISSUANCE F PAID:
} O' resat oenterupon the abroctloryioned prop author be reprexnos of this .
}� N city W)agree
to ave,Inde m Indemnify
an
property less he Cit purposes.Cu . ALTER OR ADD TO MECH.
Z (We)agree to save,indemnify an d keep harmless the City of Cupertino DB16 RCCCIPI#
V againsts.ld City.iudgmequencetof the
expensesw his may in anywayamme AIR HANDLING UMT(TD IQWE CFM) SUBTOTAL'
1 again old ❑y.in,consequence of Rhe gra nti of this pertnit. r
AIR HANDLING UNIT(OVER 1 Bow CFM) CONSTRUC TON:TAX� tis
S' mtureof Applican/Contra or ate EXHAUST HOOD(W/DUCT CONSTRUC ON TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theappllcant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCCCI I#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the —P
Health and Safety Code Section 25532(a)3 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes I]No
Will the applicant orfutum building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUAN 'DATE
which emit harardous air ma tamivents as defined by the Bay'Area Air
Quality Mawgemrnt District? BOILER-COMP DEEP OR 100,000 BTU) +'
4 Yea No
have read the bazar us materials requirements under Chapter6.95o! BOILER-COMP(OVER100,E)0BIU) A
the Cellfernla Health&Safety Code,SeRiom 25505,25533 and 25534. 1 A ' D
understand that if the building does not currently have a tenant,that it is my NEWRFSIDENTIALMECH. SQFT
responsibility to notify the occupant of the requirements which most be mel ' `•_� p A
priormlssuancc ofaCertllkato of Ocavpancy. / AUG 1992 '
Owner or authorived agent
Data ISSUEDBY11- UYrnIIIVU
7
OFFICE COPY-