21336 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Bundmg Addreas: f"I C
ty10 Boo 's Qv. G U
rare aces: one:
A
-a4S4 CITY OF CUPERTINO-BUILDING DIVISION y
Ganha wawme: / � LIe:Na: APPLICATION / PERMIT D — �—� C
h GIR ( On �O h) a �OOD O BUILDING-ELECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL
Am},Itett/Engineer. Lk.No:
I\ / QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addreu: 7j31 (Ivto AK J0,,I , SS q(SI( PERMITISSUANCE ❑ El ElLICENSED CONTRACTOR'S DECLARATION g
Ihembyafflrmthatlamllcensedur orpro WmsofChapler9(rommene- APPLIANCES-RESIDENTIAL ]OB DESCRIPTIONIngwith Sadion 7000)of Dlvidon3ofthe Busineuand PmfessionsCode,and my
Licanslicense lelnfull ls_'S' and ic.0. /' PONTIS rr
License CV Lkec I O J
Date 0 Contractor ' D UPTO"AMPS
ARCHITECTS DECLARATION
p�p�uu MPS
ail Zp I understand my plane shall be used as public records. OVERIOOOAMPS - SQ.FT.FLOOR AREA S/SQ.FF.
E� Licensed Professional SIGNS ELECTRICAL
<6 OWNER-BUPLDER DECLARATION
(i+a SPECIALCIRCUIT/M15C
Z f.,�1 Ihereby affirm that am exempt from the Contractors License Law for the .
OO followinn.(Section 7mess 1.5,Businand Professions Code:Aty or
O z" g reasony city 172AP.ME777i OR POLE INST.
pE county which requknapermit toconstruct,uires theaprovent fors ch,ormit tr
any rtatturepdemenits haaeIsalae sed pursuant applicant for of permit POWER DEVICES
to
Ilk a signed statement that he b licensed pursuant to the provisions of the
3w Contractor's License Law(Chapter9(commencing with Section 7000)of ERA- SWIMMINRIOOLELECT
O sion3ofthe Business and Professbm Code)mthm het,exempttherefromand VALUATION
E3 the Weis for the alleged exemption. Any violation or Section 70315 by any OUTLETS FITS / �O O
<5
applicant hats permit abjectitheapplicant to a civil penalty ofnot more than
fivehundreddollari(SSOO. NEW RFSID EC Sol-7. SFOwpS TYPE CONSTRUCTION
F11,ac awrier of the property,or my employerswith wages as theirsola
compensation,willdo the work,andthestacture Is not Intended or offered for
OIn&,70K Business and Perfanlmv Code:The Contractors License law
$ does not apply to an owner of property who Wilds or improves thereon,and OCC.CROUP RFS.UNITS
donsuch work himself or through Ma own employees,provided that such
Improvements are not Intended oro(fered(orale.It,however,the building or TOTAL:
Improvememt,widwithinoneyear.(completion,aheownet, Qderwlll have
t"rden of proving that he did wl Wild or Improve for purpose ofule.)• I CPER IT FEE ROOD ZONE APN
j_f L as owner of the property,am exclusively contracting with licensed C
contractors to construct the project(Sec.70K Business and Profession Code:
The Contractor's License Law does not apply to an owner of property who AL .DRAW VENT-WA
Wilds or improves thereon,and who contracts for such projects with a FEE SUMMARY
c7a4actor(s)licensed pursuant te,the Commotors License Law. pLpWEV
T.D
L_j I am exempt under Sec B&P C for this mason
Owner Date
DRAINS RR F, SANITARY Y N_
RECEIPT N
WOfirm tAN COMPENSATION DECLARATION Fp(.NRES•PER TRAP SCHOOL TAX Y N
QI hereby orlserm that I have o ce saran or consent to o y-Inarc,or RECEIPT k
certificate D.Lid,o(Worken'C.mpeneatlonluunnce ora certified copythereof f5ec. GAS EA.SYSTEM-1 C. EIS PARK FEE Y N
Policy
lab CJ RECEIPT#
Coltry s GAS PA.SYST M-O 4 )
Cany BUILDING DIVISION FEES
�Certlflad copy t,hereby furnished. GREASE/INDIISFRL WA INTE(cePTOR PLANCHECK FEG
t—vtCertifted copy b filed with the city Inspection division.
l`�C CERTIFICATE OF EXEMPf10N FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANTIARY-STORM EA 2DOFI. Date Recei t#
(Thiacection need not le completed Nthe SURA t,foreu hundred dollars
(SI00)orless.) WATER HEATER W/VENT/ELFC.TR ENERGY FEE Y N
I certify that In the performance of thework forwhlch this permit is issued,
I shall not employ any person In any manner so as to become subjett to the WATER SYSTEM Worker;Compensation laws.(California,Date PAID
OZ Applicant NEW RESIDENTIALPLMB. SQFT. Date Recei t#
Z O NOTICE TO APPLICAM:ILafter rnsking this Certificate of Exemption,you
should Moore subject to the Workem'Compenution provisions of the labor TOTAL:
N Codgyou at forthwith comply witheuch provleloumthb permltshallbe BUILDING
] drerredrevoked.CONSTRUCTION
CL LENDING AGENCY SEISMIC FEE
0. Ihereby of@mthat these is a mutuctlo"landingagenry for the perform- TOTAL: ELECTRIC FEE
D O arace.ftheworktarwhichtht,permitist,aaed(Sm3097,CIv.CJ
V Landers Name PLUMBING FEE
1- Landers Address QTY. MECHANICAL PERMIT FEE
O W Icedlfythatl have read tht,applium
lamrretionard stauthattheaboveinfovtten MECHANICAL FEE
1 ct.l4n.,tocommE<
plywithallcityandcountyordinanandgatelaws PERMIT ISSUANCE FEES PAID:
). relating to building construction,and hereby authorize representatives o(thls
N
F city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH.
? (We)agree to save,Indemnify an it keep harmless the City of Cupertino Date Recei t#
V
against liabilities,Pdgmems,amassed expenses which may In anywayaaxue AIL(HANDLING UNIT CTO 10,000 CFM) SUBTOTAL:
aga lug said City in consequence of the granting of this permit,
AIR HANDWNG I]hTC(OVER 10,030 CFM) CONSTRUCTION TAX
v
igestom of App nt/Contractor Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfulure building occupant store or hand le hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
materia)as de0ud by the Cupertino Municipal Code,Chapter 9.1Z and the
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
C� Yes No
illthe ippliciat urtbuilding occupant defied by equipment or devices VENTILATION PAN tSWGLE RESIDI. I$$IMId�AA'IE
andt Management
contamWnuas de0ned by the Bay Ares Ab T'/1#Y
ality Maugerrent rkt7 BOILCR-COMP pF4'OR IOO,IXD gTU) ,
Y Yu- No
I have read the hazardous rta/eriat,requirements under Chapter 6.95 of BOILER-(OMP(OV[R 100,000 BTU) OCT 2 51990
the California Health&SatelyCode,Sections 75WS 25533 and 25534.1
SQ.FT.
understand that lithe building does not currently have a tenant,that it is my NEWREEDFNT7ALMEunderstand �sa�((aasas,��r�sa
responsibility to aaffy the occupant of the requirements which must be met Y1v Vi �`¢ts Ga AaNa
prioo�r t�/L]c]suance o(a C�errtilkate of Oav parry.
4 AV-17)f
Owner ora hod agent Data TOTAL: ISSUEDBY:
�Ej
OFFICE COPY