23137 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Add.: /T �
s+c,Ii Lw►, na c� .sol 23137
nen oma: A -
I VIeL0 �i 11 12 4��• {e CITY OF CUPERTINO-BUILDING DIVISION
Contr ctor'sName: Lk.No: APPLICATION / PERMIT L
t BLnDINC-ELECTRICAL•PLUMBING- CATEGORY CONTROL p
MLCHAMCAL G CQ-'J
Arc ect/G neer, Lie.Nre
QTY ELECTRICPERmrr FEE BUILDING PERMIT INFO
Addrcs: PERMITISSUANCE T 6 ❑ ❑
LICENSED that ED CONTRACTOR'S DECLARATION
withb af(nm )olacolicsnsed 3oftheunder uMnesssiomo(Cslonsr9de,and e- APPLIANCESREED NTIA DF_`�-tB'�
Ingwiel.i. 111mceof Dlvlect. flheguslnesandPro(esalonsCode,end my V lam„
license Is in fuB(ora and d(ed, PANES
License Clan LICM /
Dale Contractor
ARCHITECTS DECLARATION
reOO Iundnslandmy plans shallbe used as public record.. X1000 1' AR IE{s`Q�FI'.
k z Licensed ProfesaLmid SIGNSELECTRICAL �� N
<6 OWNER-BUILDER DECLARATION
j'n a SPECIALCIRCU134SC
Zs- I herebyafloo that l am exempt from the Contractors Lt..law for the
po fallowing....(5nod..7031.5,Business and Profession.Code:Any dty or
OZ—qq TEMP.M ORPOLE]NST.
rounty whichcture requlresapermitto cow requimstheaprovgdernallsh,or repair GATE
g ❑❑ any structure statement
that
he Is also sed pursuant t the emboonsorsuch ofpermit e PO DEVICES
k5 ry1 y� lite a signed statement that he V licensed pursuant to the provisions of the
Cot
�+ Contractor'.License Law(Chapter 9(commencing with Section 7000)of Dlvi- NG POOL ELECTRIC
' �Og sion3oflhe Businessand Profealmu Code)orthat hehexemptiherefromand VALUAI7
6 the basis for the alleged exemption. Any violation of Section 7011.5 by any OUTLETSSWITCHFSHXTURES
applicant fora perms subjedsthe applicant to a civil penalty of not morel 3 d�0
five hundred dollars($SOO). NEW RPSID=AL ELECTR SQ.FT. ' CONS'1l2UCTION
F1 1,as owner of the property,or my employees with wages as their sole STOIiI S
�7Q compensation,willdotheworkandthestrudurebna intended or offered for
5 O .1.(Sec.7006,BusirtesandProfessore Code:The Contnctoes Lkxmo,Law
[ $ does nM apply to an owner of property who builds or imre
prov.thereon,and OCC,GROIIIa RES.UIJD'S
cc.. who do.such work himself or through his own employees,provided that such
Improvements are not intended oroffered in...le.IL h n,owat thebuilding or TOTAL:
Improvement issoldwithlnoneyearofcompletim,the mvner-bullderwill have
the_kurden of pmvinglhat he did notbuild or Improve for purpose of.ale.). QTY, PLUMBING PERMIT FEE FLOODZDNE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to romtmct the project(See.7046,Businem and Professors,Code;
The ContmRors Llanx Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon, and who contracts for such paoleds with
cgR[�adarts)licensed pursuant W the Contractors License Law. RACK FLOW PROTECT.DEVICE ..,FEE SUMMARY
LJ I am exempt under Sec. B&P C for this reason -
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N�
Owner Date' - gpDE1170
WORNAIAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOL I'A% Y_ N—
❑I hereby aHlrm that I have a certificate of consent to.elf-Insure,or RECEll NM
certificate of Workns'Compereatlan Insurance ora certified copy thereof(Sec. GAS EA,SYSTEM-]INC.60UTLETS PARK FLB Y N
3800,Lab C.)
Policy p RECCAS EA.SYSTEM-OVER d(EA) DING TH M
Com any BUILDING DI VISION FE FS ropy b hercbytumecity GREASE/INDUSTRL WASTE INI'ERCETOR PLANCHECKFEE T+++m
❑ ished
Certified copy b filed with the city Wpectlon division. -
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRM pAlp ZM9-1C1% XX
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA ZOOFT Date Recei t#
Ghi..ection need not be completed if the permit isfor on hundred dollars
($10D)orless.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certify that In the performance of the work forwhich this permit is blued, —
I shall not employ any person In any manner so as to become subject to the WATIR SYSTEM/TRGTING
Workers Compensation Laws of California, Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Remi [#
Z O NOTICETO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Worken'Campemallon provlalom o(ehe Labor TOTAL:
fA
Code,you=at forthwith comply Mthsuch provisions orthb permit shall be s a0
LU j deemed revoked. BU FEE
aO CONSTRUCTION LENDING AGENCY SEISMIC FEE T
Z Humby.fOrm thatthemis a cnmtmction lending agency forthe perforrry TOTAL: ELECTRIC FEE �(.S�
once eea Namrk for which this permit is l dmdl(See.3097,C1v.C.) _
V O Lenders Name PLUMBINGFEE
LL 1- Lander'.Addreaa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Ian ify that l have read this application and sate that theabovelnfomutlon
IL tsco�d.I agree to comply with all city and county ordinances and state law. PE2MUISSUANCE FEES PAID:
>. W relating to building cors,buctlan,a reby authorize representatives of this
(— Z ciy;ee)n.
on the above-me o property for trepedlon purposes. ALTERORADDTOMECH. Date Recei f#
_ to seInde ty a d keep harmer the City of Cupertino Pages,Jodg rats odde rases whtchmayinanywayaccme AIR HANDLING UNIT(TO to,"CFM) SUBTOTAL:ot n (1 an Is it.
�l AIR HANDLING UNIT(OVER 10,"CEM) CONSTRUCTION TAX
u cof App rat/C ntmctor / re E%HAUSTIIOOD(W/DUCT) CONSTRUCTION TAX PAID:
S :
HAZARDOUS MATERIALS DISCLOSURE
Will the appllarit or future building occupant store or handle havardous HEATING UNIT(TO 100,ODO BTU) Date RCCRI f# a 3
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Cade Section25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes M No
Will the applicant or future building occupant use equlprorot or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which coat harerdous air contaminants as defined by the Bay Area Air PAID Quality Management District? BOILER-COMPQHPOR 100,0M BTU) P psi Y D
'?have Yca N No
mad ealthhe a our Code, a 1..,2men,25533 Chapter.1 of BOILER-COMP(OVER 1fD,000 B'fU) _
theCIif
understand
d t Health&Safety Code, of currently
ntly h b533 and 75536.7 JUL 14 1992
unporadndshatn notihe fy
the ing doesoccupant of tcerrentlyrrent.ave a whicna h
thatb limy NEW RESIDENTIAL MECH. SQ.I7
responslbllity to notify the occupant of the rcquircrrtenia which must be met ''
prior to lsuana of a Certificate of Occopa my. CITY U� WPE
fl&r` /
Owncr or xuthorured agent Date
TOTAL: ISSUED BY: _ _
OFFICE COPY