22945 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Praia I Identification T PIRMITNO.
Building Address:
10123 wo a 2294
saner. ams. one. A AL A
(_42> 4j CITY OF CUPERTINO-BUILDING DIVISION
. Contractor's Name: Lle.No: APPLICATION /PERMIT �6
TZ W BUfLDING-ELI)CMCALPLUMBING.MEC MCAL CA=RY CO OL M
ArchitcctLk.No:
1✓ 0, E)„` 1` QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:GIQ �� "l-0. S PERMITISSUANCE ❑ ❑ ❑
11CI I RD CONTRACTOR'S DEC ATION
I hereby affirm that l am licensed under provisions of Chapter9(cemmen APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwlth5edton7000)of Division3ofthe Businessand ProfessionsCods,and my
license Is In full force and effect. PANELS
V Class LIc.N
Date P_1 xf Vil,V
Date Contractor E' l LLL 111 1/`
ARCHITECPSDEC ublicm moods,
OVFR(CAMPS
urc0w O I understand my plans shalt be used u public records
OVER 1(00 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
4E Licensed Prefeau,mal SIGNSELECTRICAL L E D IN
OWNER-BUILDER DECLARATION SI'ECIALCIRCUfT/MISC
ZL, I hercbyaffirm lhatItuno mIn from the Contractor's Limme Law for the
following reaum.(SMion 70T1$Business and Profenom Code:Any city or TEMPMETERORPOLEINST.
ro
�Q countywhkh rnryirnaperMttommwd,altcr,lmm
pmve,deolbh,orrepair
anystm=mpdortolts Wuamc alsorequi theappBrantforsuchper tto POWER DEVICES
file a signed statement that he b licensed pursuant to the provisions of the
Contractors License Law(Chapter 9(rommencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC - VALUATI
O sion3ofthe Buknessand Profmss mCode)orthahelsexemptthemfromand e Q
< the basis for the alleged exemption. Any vlolatl.n cf SedWn 70115 by any OUTLETS-SWITCHE&FD((URES
O appllantforaper t=bje theapplkanttoadvllpemkyofnm=mthan O 7r
five hundred dollars(S500). NEWRESIDENTIALELFOTRSQ}7. STORIES TYPE CONSTRUCTION
! c F-11,as owner of the property,or my employees with wages as their sole
ompematlon,willdo the work andthe structure b not Intended or offered for
Osok(Sec.7094,Buaincvand Profesalons Code:The Contractors License Law
$$ does not apply to an owner of property who builds or improves thereon,and OCC.GROU11 RIS.UNITS
whodoessuchworkhlmself orthrough hlsownemployen,provWed thatsuch
Improvements are not Intended uroffered forsak.If,however,thebullding or TOTAL:
Improvement issold withmoneyearofcompielon,the owner-builderwlll have
it rden of proving that he did not build or improve for purpose of ask.). QTY. PLUMBING PERMIT FEE HOOD ZONE APN
t L as owner of the property,am exclusively contracting with licensed 1'ERAILL LSSUANCE
ceniractors to mnstrud the project(Sm.7044,Business and Professions Code:
The Contractor's License law does net apply to an owner of property who ALTER-DRAIN&VENT-WATER CEA)builds or Improves thereon,and who contracts for such piojects with a FEE SUMMARY
,,Ntil(Tactor(.)licensed pursuant to the Contractor's License Law. BACKFLOW PROTECT.DEVICE
on
I am exempt under Sec. B h P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
• Owner Date RECEIPT=
K
WORMAN COMPENSATION DECLARATION Fp(T.URpS PER TRAP SCHOOLTAX Y N
MI hereby M.that I have a ou tiBrets of convent to self-Insure,or a RECEIPT 0
on iflceteofWorke Compemationlnsuranceoracertifledcopythereof(Sec. GAS EA.SYSHM.I INCA OUTLETS PARKFEE Y N
3800,lab C.) RECEIPT p
Gg,,aPolicy GAS EA.SYSTEM-OVER 4(EA)
Co�mppany BUILUINC DI V ISION FEES
I CedlRed copy b hereby furnished. GRFASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
hd@(CertlBed ropy Is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA MET Date Recd t#
(Thissedlon need not be completed lithe permit is for..hundred dollars
(B1001.r 1ess3 WATER HEATER W/VENT/E.ECTR ENERGY FEE Y_ N_
I anify that in the pedorman<e of the work(or which tin.permit b blued,
I shall not employ any person in any manner no as to become subject to the WATER SYSTEM/TREATING
Worken'Campensatkm Uwe of California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Recei t#
Z NOTICE TO APPLICANT.IL after mak!ag this Certificate of Exemption,you
O should became.ubjed to the Workers'Compensation provisions of the Labor TOTAL:
I— W Cods,you=atforthwith comply with such provisions or this permit shall be 6 I TNG G
ILK 9 deemed revoked. SEISMIC FEE a
CONSTRUCTION LENDING AGENCY
There'syafBrmthmtherebaconstIsisenkndec.309,Civ. he pedorm TOTAL_ ELECTRIC FEE
7 Z Leas,the work for which this permit Is issued(Sec.3097,Civ.C.)
O O lender'.Name PLUMBING FEE
LL I— Lendersnddresa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U Icedifyth t I have read this application and sialethatthe above Information
O W bcorrcct.7 agreetocomplywith all cityand cou o rd state laws PERMIT ISSUANCE FEES PAID:
} relating to butidln on trudion,a au o rcp.n tivesofthb
N ALTEIt OR ADD TO MECH.
F Z dtym enter ups heabov menti and pm f Fiction uryoves. Date Receipt#
t .ave,l e a d r ss the CI of Cupertm.
V ngalntl it a 7adg rt, sts d xpen w chmeyi nywayaccree AIR HANDLING UMT(TO lO,OWCFM) SUBTOTAL: 2 _
agai{tt a mco e ce he gradin of his it CONSTRUCTION TAX
6 AIRHANDLINGUNIT(OVIR10,(00CI•'M)
Sign ores(App cam o tractora DaiAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS I)IS SURE
Will the applicant or fumm building occupant store or handle hazardous HEATING UMT(TO 100,WUBTU) Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 93Z,and the
Ilealth and Safety Co% ton 25532(a)T HEATING UNIT(OVER 1 W,"JI ) TOTAL:
❑ Yea
Wiltheapplicant rd T(v�ore building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISWAAq MITE
whichemit hazardous air contaminants as dented by the Bay Area Air
Uu a lily Marugem°n[ !strict? BOILER-COMP DEE'OR 100,0(0 BTU)
4Y" "° NOV G 1991
have read cosh matedab rcquiremenb under Cha 6.95 of BOILE&COMP(OVlIIt 100,WOBTU)
the CalifornUHealth Safety Code 25 -533and25SM. I
undenaan that if a uEdi. d m curr l ave enar,that it is mH.y NEW RESIDENTIAL MECSQ.FT
responsib'i to 1 the p mere m
tswhirh stbect CIIYUI- uurcmIINU
prior'. c f Ccni to c �/(/jam/��{'
Owner o agent �Oa`e'
TOTAL: ISSUED BY '
OFFICE COPY