23789 APPLICANT TO FILL IN INFORMATION_WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PER•MITNO.
Balding o:3 rook Dr e,4 eV G R5o y 23.789
mere amp: _ ane: .
/ 258-12D CITY OF CUPERTINO-BUILDING DIVISION
4 Contmoce.Name: Lt..Nce APPLICATION I PERMIT Z
•f' CG& /S /2• BuiLDING-ELECTRICALPLUMBING-MLCFIANICAL CATEGORY CONTROLM
rchltea/Engineer. Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addreac� �� f
PERMIT ISSUANCE Q"� ❑ El
LICENSED CONTRACTOR'S DEC" ATION LJ�J
I hereby affirm that l am licensed under provisions of Chapter9(mornmr, APPLIANCES-RESIDEMTAL JOB DEECtUyHC)N
ingwith Sectlon7000)o(DiWgm3ofthe Businessand ProfcWmsGode,and my
limes¢is in fug(. end effect. 5/s PANELS
DateConlnctor
AmaMU CTS public rd 1-100AMI5
q�q�uu 070. I underhand my phns stag ba used u pubec temnls VER 100 AMPS SQ.Pi.FLOOR AREA f/SQ.FT.
Fi LIceuM Professional NS ELECTRICAL li Q 'r') 0
/yl
�:lq OWNER-BUILDER DECLARATION SPECIALCI4CUIT/MLSC' /Sr' f /
Thereby a(Brenthat l am exempt the Contranor's License Law for the
Zpo, a
O Z F 3 following reason.(SRion 7031.5,Business and Professions Code:Any city or IFld
p� manly which requires a permit toconstruct,alter,Improve,demoish,orrepkir
q anystmu mprlortoibissuance,atsomqul theappU=tfosu hpermitto TOWER DEVICES w�ha O O
ES Rlea signed statement that he is licensed pursuant to the poevlalons of the _a...-- .
wr. Contractor's License Law(Chapter 9(mmemorma with Section 700)of Divi- SWfhA9NC]OO VALUATION
OJ ste basis fo thealleedProfessions Any)virthrtheb exempt therefrom and
E5�n...7777 the Gek for the alleged exemption. Any violation of Seaton 7041S by any /
< a p ntlot ated tl t(aubjects he applkant to a civil penalty of nes more than O�-E�" I/
Q
netted
dolhn(f50. NEW D TR FF. STORIES TYPECONSTRUCTION
000 �n a owner of the property,or my employees with wagesas thele sole
c mpereatim,willdo the work and lhestroctureis not Intended or offered for ,
Osale&c.7044 Business and Profeaelou Code:The ContraRofs License Law
does not apply to an owner of property who Wilde or Improves thereon,and <eN ON OCC,CRO(11s RES.UNITS
whodoessuch work himself orthrough his own employees,provided that such /�
bnprovementsare not intended oroffered forsale.If,howevegthe Wilding or V TOTAL:
Improvement issold wlthinaneyearafcompletlon,theowner-bullderwgl love
thLIsurdeno(pmving that he did not Wlid or Improve for purpose of sale.). QTY, PL INC PERMIT FEE FLOOD TONE APN
"L u owner of the property,am exclusively contracting with licensed PERMITISSUANCE Je� -a i
contractorsto moelrva the pmject(Sea 7044,Buhness and ProfesslonsCade: 9
The Contractor's License Law dm net apply to an owner of property who ALTER DRAW&VEM-WATER(EA)
Wilds or Improves thereon,and who commas for such project with a
cgB(pdorts)Bcenxd punuatto the Con tractor's Llxnss Law. BACK PLOW pItOTECT.DEVICE FEE SUMMARY
U I am exempt under Sec. 0 k P C for this reasonOUTSIDE FEES
Owner ` Mt✓ Data
DRAINS FLOOR ROOP,AREA,COND. Q7 SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATTIION FDCIURES PER TRAP - SCHOOLTAX Y��Np_
❑I hereby affirm that I have a certificate of consent to sect-Inwrr,or a _ p
certlfimteofWorY m'Compens fimlnsunnmoaadifkdmpyth..f(Sec. RECEIPT GAS EA.SYSIiM-1 WC.6OUTLETS PARK FEE Y N
3800,Lab C.)
Policy p GAS EA.SYSTEM-OVER 6(EA) RECED'P p -
Com any BUILDING DIVISION FEES
�CertNed copy is hereby furnished.
thcity
e city ty
Certified ropy V filed with
thInspection division. CREASEANDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
❑
CERTIFICATE OF EXEM PTION FROM WORKERS' GREASE TRAP PAID / C0
COMPENSATION INSURANCE SEWER-SANITARY-STORM F.A.RIOFf. Date Remi t#
(1'hiaseabn need nes be completed If the permit le(cross hundred dollen
(gl I esmless.) WATERHErTFRW/VENT/ELECTR -�•� ENERGY FEE Y N
Icenot thato any he
In
tmanner an as tdNlNspeonhis issued,.the /�
1 shall not employ any person In any manner m u to become vtbjea to the WATER SYSIUA/TREATING
Worken'Campensallon laws of Call(amla.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
Z 0 NOTICE TO APPLICANT:If,after nuking this CertRlotecf Exemption,you
cc ya should become subjectto the Workers'Compereatim provisions of the Labor TOTAL:
Code,you=at fel hwlth comply with such provisions or this permit shalt be BUILDINGE O
> deemed revoked.
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
0. 5 I hereby afBrmthat there k a cam ualon keding agency for the perforrir- TOTAL: r� ELECTRIC FEB '7
b.
0 Z e oflhe work(.,which this permit is Issued(Sec.3097,Civ.C.)
V O anc
Lewes Name PLUMBING FEE
LL F Lender'sAddr`x QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W are
Irtlfythatl have ad lhbcppliow tionaextethat theabove Information
1 Isearrea.lagreetocomplywlMaHdtyawmuntyordinancesandstatelaws PFRMITISSUANCE FEES PAID: _
} M relating tobuilding construalon,and hereby authorize representatives of this
H Z city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MFCH. Dale Reeei t#
V — (We)agree to save,Indemnify an d keep harmless the City of Cu pertbe P
against liabilities,ydgerms,meteand expenses which may In any way amue AIR HANDLING UMI'CFO 10,000 CFM) .SUBTOTAL:
gh Bald City In conecqucke o�,y¢granting of this permit.
a Q U�,-� 9-9� AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicant/Contracts Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfmure building occupant atom or handle haardous HEATING UNIT(M 100,000 BTU) Date RCCCI t#
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the
Health and Safety Cade Section 2SS32(a)7 HEATING UNIT(OVER 10,00 BTtN TOTAL:
❑Yee No
qV
Will the applicant or tum building occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
whkh emit haardea s abmntandnsnteas cleared bythe Bay Area Air p� p
Quallty Management Dbtrid7 BOILER-COMPOHPOR 10,000 BTI!) r W
❑Yes No
Ihaveread Healthe h
Safety Code,Sections
ro5533 anhapter G95 of BOILER-COMP(OVER 100,000 BTU) -� 992
the
understadt Health kSafety Code,Sealons25505,ve a tenant,
JUN
f
mapoesandttot if the notify
the
hoccupding ant of the currentlyhavetenant that itlimy NEW RESIDENTIAL MEGA. 5Q.FT 1V
spoulbs a to of aCtheoccupantoftherequlremente which must be met
prior to issuance ofa CertiOcete.fOavpanry. I'Ur d;&'ChIJISIU
Owner or aulXoriad agent Data
TOTAL: ISSUED SY:*4_.__!_ \%
OFFICE COPY