19788 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulldlea Pm'eccttII-dentifiation PERMIT NO.
Byu Aad ,. z l!//+'wax , Yof ' 1 S s.z 7 9`1 - 19788
uwneie Na�me�(♦'/' Phone: AI•PUC ONSUBMIRALDAIL
CITY OF CUPERTINO-BUILDING DIVISION /�dI�O
Contnnor'.Name: Lie.No: APPLICATION I PERMIT ��(( 0/
'.fit•�±..•,.���� P�`'��3 BUILDING-ELECTRICALPLUMBINC-MFFHAMCAL CATEGORY (CONTROL 1I
*Arch/Frgineer. o�/ r o:
t. ' " BUILDING PER
MIT,INFO_;'.�`^ .t
" }�'[-':ELELTRICPERMITµ=- �` FEE. I i
Addres•♦z""1 `/Sf¢ Ce ,PERMITIS5UANCE
"` LICENSED CONTRACTOR'S DyC AT APPLIANCES-RESIDENTIAL i
er common ` ['OBDESC/R�RMON
ingwith Section 7000)of Dlvision3 ofthe Buslnesaand ProlessionsCode,and my
PANELS
C/-r•1/j�N� K
bmnse is In fu to�rte�]nd effect I /� ✓���
License Class rtic.Y Va% 2 9 /
Date?- 2_ F-Yi Contractor 1TJQ_200AMPS
201-10(s)"PS !\
ARCHITECus DECLARATION OVFR I"AMPS '\ /Y SQ.Fr.FLOOR AREA $/SQ,Ff.
❑z ZC 1 understand my plan shag be used v publi<remrds ,1
r-u tj Licensed Professional SIGNS ELECTRI AL
?� OWNER-BUILDER DECLARATION SPECIALCBKUI ♦ �� r
t- z Ihembyaffirmthat l amexempt lromthe Contractola License hw(or the o
pp following rea.on.f5msion 7ai Business and Prolevbm Code:Anycity.r TESP.MFITROR INSry 1�
U4 county which requires a permit m
at toeatruct,alter,improve,deoilsh,or repair , lV1
<L-I. iny.trocum,priori.It.bmance,aleo equirestheapplIcant forsuch permit to PO D 1
file a signed statement that he is licensed pursuant to the provisions of the - I
O-O
Contractor's License Law(Qupter9(mmmencingmthSemion7)0))of Divi- d); �E
153-ON sion3.fthe Buiderasand ProfessioruCode)orthat hebesempitherefromand r C' _ / VALUATION
Ir 5 the basis for the alleged exemption. Any xn.laHOn of Senl.n]015 by any O TCI-ESFES I\ I [ �Q• coo t2 A appilantfora permiUthisce,heappgcant to a civil penalty of not mars than 11� J r
^�R live 1,as nerofthepr. NE ESIDEN'IIALELFIrIRI ( STORIES I TYPE CONSTRUCTION
l is.-, ❑Las owner o!the property,or my employees of in wages r their sole I
I_2 compensation,(Se.70 wBldo the w.rkand
ssumut rucie:TheC dracted.rcense La
;7�o sale(Sec 709y to an owner of property Code: or impcors Lirea 1
does whodoessuch torn.wnero(prough his anempeyces,povided thereon,and I� I OCC.CROUIs RES.UNITS thatsuch
whodoementsa not intended hroagh huownemIf,how,providedilding or IT
Improvemenb are noHntended oro((ercd(mmle.If,however,the bwlding or J OTAL; -
improvementbwldwlthlnaneyearof completion,lheowner-Wgderwillha 1,),.. 1i 1
theburden of proving that he did not build or improve for purpose of bale.). S '�„�FEE.Y 41 FLOOD ZONE ArN
E]L ae owner of the property,am exclusively contracting with licensed PERMILISSUANCE
rontracton to construct the project(Sec 700A Business aM Profemlons Code:
The Contractors Lim..Law don rice apply to an owner of property who I
builds or improve thereon,and who contracts !or such p(olecn with a ALM-DRAIN&VENT-WATER(EA) �'♦°ii`•i..,F.+'•'v.:TEES UMMARY p
royuaR0 truism order Sec, the Coneneole Llmnse Law. BACK FLAW PROTECT.DEVICE ' '
LI I am exempt under Sec B&P C for this reason OUTSIf1F FFFS
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
- -.Owner Data - _ RECEIPT N
WORINIAN COMPENSATION DECLARATION FTXNRFS PER TRAP SCHOOL TAX Y N
❑I hereby alfirm that I have a mitlRote of consent to self insure,or a RECEIT T e
mrHBam.m.r1mos Compensator,I...ors certified copy thermf(Sec. GAS EA.SYS77EM-1 INC4 OUTLETS (PARK FEE Y N
meal iAb C.) RECEIVE N
C. Y GAS EA.SYSTEM-OVER 4(EA)
Policy BUILDING DIVISION FEES I
�Certiiled copy is hereby fumiahed. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certifled copy b filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEINER- STORM-SNRM FA.7DDFI I Date Receipt#
(fhb union need not be mmpleted Hthe permit is lure.hundred dollars
(510))orlen.I WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
I certify that he the perlmnunce of the work forwhlch this permit is issued,
I shall not employ any person in any manner eo as to became aub*d to the WATER SYSTEM/TREATING PAID
Workers'Compensation Lisa of California.D••^
Q Z Applicant --_� NEW RESIDENTIAL PLMB. SQFf. Date Receipt#
Z NOTICETO APPLICANMIf,.hermaking thfa Certificate of Exemption,you ,
Nshould became subject to the Workers'Compereatlon provisions With.Labor TOTAL: �A I
Code,you=at forthwith comply with such provisions orthb permit shall be (BUILDING FEE -7.kr.4 I
W > deemed revoked.W
— CON5T0.UCf10N LENDING AGENCY �SEISMIC FEE a SO
CL Thereby a(Orm that there bamnstmctlon leMingagenry(or the perfcmmo-j TOTAL: I eLECTRIC FEE
= Z ance.f the work which this permed te I ssued(Sec309'/,Cle.C.)
0O lender'.Name Vy;' `Tv-'•-FEEet PLUMBINGFEE
IL H Lnndels Add,- -- (QTY• -�y,'MECHAN[CALPERMIT�i-aT 11ECHANICAL FEE I
U I anLfythat I have mad thbappInformation tionani samthatthe above Information
O W bmrrect IAgreel.complywltha0atyand muniyonlinanmand gate law.I PERMIT LSSUANCE (FEES PAID:
} G relating to building comtmc Hon,and hemby authorize reprosematvoalthb
I' Z styt..eterupon the above,memloeed property for Inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemllfy an d keep harmlen the City of Cu pen[no
Date Receipt#
U agaWt BabiHtles,Pdgmente,ores and expen.n which may in anyway accrue AIR HANDLING UNIT(T010,000 CFM) I SUBTOTAL:
nst seld City sequence of the granting of this permit.
NR HANDLING UNIT(OVER
10,000CI•M) CONSTRUCTION TAX
--oil z - 27 CONSTRUCTION CONSTRUCCION TAX PAID:
Sig Lure of Applicant/Contractor Data EXHAUST HOOD IW/DUCT)
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant in future building occupant store or handle haaardous HEATING UNIT(TO 100,000 BTU)
Date Receipt#
material and Safety Code Section 25532(a)?Municipal Cade,Chapter 9.l2,and the - -
HealthandSa fety Code Seniors 75532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑
Y. UN.
Will the applicants futum building occupant use egmprnenl ordewms VENTTLATIONFAN(SINGLERFSID) ISSC)%k*6ATE
which emit havrdous air contaminants as defirmd by the Bay Amen Air
Quality Management Dlstict9 BOILER-COMP DHE OR 100,000 BTU)
❑ Yea Rff No
i Ihaveread the hr, ffmsmteriabrequimm ntsunder Chapter6.95 of BORER-COMP(OVER 100,000 BTU)
the Calif.mu Health&Sifcly Code,SmW.2550'5,FS33 and 25534. I
understand that lithe building den notca eatly have a tenant,that It is my NEW RESIDENTIALMECH. SQ FT. Litt] Df P.imortIBO
rnp.nsibdity t.ramify the occvpa rat.(the requvemenb which rnu.t be met
uce of Ce teL.f Occupancy. /n/
7,9fro`ea_t”onee dagent Date IISSLTJ3BT' zw 4a C C1 TOTAL:
OFFICE COPY ��