23115 (2) APPLICANT TO FILL IN INFORMATION WITHIN'RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: 2 3115
rs anta e: /J one:
C T �• - A k=-
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CITY OP CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT /
Ohl/ 7, OUILD1NGELECTRICAI ML BING.MECHAMCAL CATEGORY CONTROLM
Amhit¢d/Fngiocer. Lie.No:
QTY ELECTRIC 1.PERMIT FEE BUILDINOPERMIT INFO
Address: PETMITISSUANCE ET I❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provblonsof Chapter 9(rommene. APPUANCESRESIDENTIAL TOB DESCRIPTION
tngMthSMlon7000)of DiWslan3ofthe Buslnmand ProfessloesCode,and my - w ' - �'/� 1,0 a
Ilcenx l"Ry"In fi18 f rce a effect. PANELS / !LG• V
- Lirenss99 ClG LIc.M tl a1 '•s'II' L/LY//
Date7'5 Contndor /b
ARCHITECTS DECLARATION ,. 201-I000 AMT'S as
1pp1�+�aO Zp Iunderstand eryplanashalbeueed aspubiiceecords OVER 1000 AMPS US RA $/SQ.PT.
E Licensed Professional SIGNS ELECTRICAL VT
R
< OWNER-BUILDER DECLARATION SPFGIALCItCUT/MISC
71.., '� Ih...byeffirmthat lam exempt lromthe Contractor's License Law lm the nn /�
oo following reasons.(Section 7031.5,Business and Professions Code:Any city or O�
FZW'� county which requires a permit to commod,alter,Improve,dernalbh,or repel r TEMP.METER OR POLE INST.
a any structure prior to Its Issuance,also requires the applicant for such permit to ppyyER DEVICES
yN V file a signed statement that he b Brensed pursuant to the provblom of the
w� Contradore License Law(Chapter 9(mmmmcJngwohSed1cn7(X0)of Divi- SWIMMING POOL ELECTRIC VALUATION
ti�Os tlon3ofthe Butmemand Profeulom Code)orthathelaermpttherefmmand
Qthe bait,for the alleged exemption. Any violation of Section 76315 by any OUTLETSSWITCHESITXTURFS
applicant for a permit subjects the applicant to a civil penalty of not mom than
five hundred dollars(¢500). NEW RFSIDLNT[AL ELECTRSO.FT.
F11,as owner of the property,or my employees with wages"their sole STORIES TYPECONSTRUCTION
compemation,will do the work and the structure Is not Intended or offered for
Osale(Sec.7094,Home.and Professions Code:The Contractoes License Law
$$ does not apply to an owner of property who Wilds or Improves Ihereo ,and OCC.GROUIP RES UNITS
who doe.such work himself orthrough his own employees,provided that such
Improvemen'..M.t lntendM proffered forule.i(hawevep thebullding or TOTAL: '
improvement bsold within one yearofcompletlon,the owner-buBderwlll have
t"rden of proving that he did not build or Improve for purpose ofule.). QTY, "PLUMBING PERMIT FEE FLOODWNE APN
LJ L as owner of the property,am exclusively contracting wlth'Ilreneed pERMR7SSUANCE /
contractors 64,to construct the project(Sec.70Business and Profeulom Code: a �
no Contndore License Law does not apply to an owner of property,who ALTER-DRAIN&VEYT-WATER(EA)
Wilds or Improve.thereon,and who contracts fee such projects with a
gq
15.mu(W)licensed pursuant to the Contractor's License Law. BACK PLOW PROTECT.DEVICE FEE SUMMARY
rI am exempt under See B&P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPT It
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N
hereby affirm that I have o Tears to of consent to self-insure,ora RECER'T N
3800certicote olWorken'Compensatlonlnsurance orecertified'ropymemo((Sec. GAS EA.SYSTEM-1 RICA OUTLETS PARK IFS Y N
38 W,GbCJ .J
I'aliry p—/Aft't/7��L1��.
RECEIPT
NGDIV
Camnany �i7� T7 ♦ GAS EA.SYBTEM-OVER4CIA) BDILDING DIVISION PP:IiS
QCertl ed copy b hercbyth the city
rtRled copy b;filed with the city inspection division. GRGSIS/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Recel t#
(Thi,xctlon need not M compidM it the permit ls!prom hundred dollars
($100).,le®.) WATERHrATERW/VFNT/ELECTR ENERGY FEE Y N
I certify that Nthe person iaofthework so as tobfhbpenultct Issued, —
I Whale not employ any person In any manner n m to beconn vub)ad to the WATER SYSTEM/TREATING
Worken'Compeneailon Lowe of California. Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.Ff. Date Recel t#
Z O NOTICE TO APPLICANT-.It,after making t his Certificate of Exemption,you
Hshould become subject to the Workerd'Comperoatlon provisions of the Labor TOTAL:
v_T Code,you must forthwith comply with such provisions orthb permit shall be B •E
W > deerred revoked.
G CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Iherebyaffirm thatthereba comtmctlonlendingageeyfortheperTorun ELECTRIC FEE
Z ane of the work for which thbpereelt b issued(Sec.3097,Civ.C.) TOTAL:
02 lender's Name PLUMBING FEE
LL Iandre.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I artilythat l have read thisappllcaHonand statethatthe above Information
IL brorred.I agreeto complywith all etyand county ordinances and pate laws PERMUISSUANCE FEES- P D:
in relating to building construction,and hereby authorize repremntativesof this �Q
I— Z city to enter upon the above-exceloned property for lmpedloo purposes. ALTER OR ADD TO MECH. /—
(We)agree to ave,IndemN(y an d kmp harmless the City of Cupertino Date Receipt#
agalmtl biline,judgments,mets and ex coxa which may in anywayaccrue AIR HANDLING UNIT(TO I0,000CFM) SUBTOTAL:
.gal tyinmveque eofth ti Bof thispermit. AIR HANDLING UMT(OVER IQODO CIM) CONSTRUCTION TAX
l d L
SI m roof Apples Com,dm to FXHAUS'THOOD(W/DUCT) NSTRUCTION TAX PAID:
HA2ARDOUS MATERIALS DISCLOSURE -
Willtheapplianlorfniurebulldingoccupanlstoreorhandleh=ardous HEATING UNIT(70 100,000 BTTp Date RCCCI f#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety Cade Section 25532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yea M No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) IS,SSUAf1%ATE -
which emithaeardousair rontaminantsasdefind by the Bay Area Air 'o �1 �jL�7
Quality lVamgerent D❑istrict? BDILER-COMP DH P OR 100,000BTU r
4 ycs d No
havo,ead teeth& outmode,Soreers 255 requirementsunderand
6.95 of BOILER-COMP(OVFlE I00,OW 8TUI JAN 10 1992
the Gltand t Health&Safety Code,Sed1am currently
have
a to ,that i 1
understandthat if the the occupant
of not herrentlyhavee tenant, b Is NEW RESIDENTIAL MECH. SQ.17.
peortaibua to ceofaCtheoccupantoftherequlmrrenb which rrwsl be met Ts -
priortoLssuanceoles Certificate ofOccupanry. �I.IY U CUr CIl I INV
Owner or authorixTOTAL:d agent Date ISSUED BY:_�1.//1
t♦ -
OFFICE COPY