23087 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL NUIN I FtN ONLY
Raudin Protect Identification PIIdMII'NO.
' Building Addms:
lot2ct, eft%k"tvo v ZSTf� O2-, 23087
MrB a1K: CY' role:
Ut Q73 13 CITY OF CUPERTINO-BUILDING DIVISION I ^ l l A
Lie.N. APPLICATION / PERMIT !r
•Archllect/Engineer BUILDING E.EYTRICAI.PLUMBINGMEGHAMCAL CATEGORY CONTROL e
Q ELECTRIC PERMIT ,,FEE "' BUILDING PERMIT INFO:
Add...
PFRMITISSUANCE ❑ ❑ I ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under pemislons of Chapter9(mmmen. APPLIANCES-RESIDENTIAL JOB PSCkfIPHO
tngwith SMion7000)of Di"slon3ofthe Buslncmand Pmfeasl...Cade,and my
license Is In NB a forand effect. PANELS
Limn am Lie Y /
Date Contactor /'_ JbUPTOMDAMPS
ARCHITECT'S DECLARATIO 701-1000 AMPS
'00= I understand my plans shall be used u public reouds. QYER I ODO AMP$ r .cQ, tis EA S/SQ.FT.
Glared Prod ssl,nsl SIGNS ELECTRICAL r
D IN
<g OWNER-BNLDER DECLARATION SPECALCIRCUJT/MLSC M P U T E R
I herebyaffirm that l am..:pt from the Contractor's License law far the
following reason(Beeian 7031.5,Business and Pm/mbru Cade:Anytltyor Tp�p MECE]20R POLE INST.casntywhlch requires.Perm wcorutrucyalter,tr pmve,demolbh,ormpar
5 anystmchmelmortoltsbasaneer,•borequirestheappBuntfaauchpermltto TE
5 Ile a signed statement the he 4 Omand pursuant to the pro irons of the POWER DEVICES
e Come a res License law(Chapter 9(commencing with Section 7000)of Divi-
^05 son 3 of the Business and Professions Code)or that he IsSWIMMINGNG POOL ELECTRIC esempt threafrem and VALUATION
the Wait
for the alleged exemption. Any Aolatlon of Stamm 70315 by any
71 pp pe subjects the appheanLoa tlWl penalty of no morethan OU7LETSBWITCFiESF(XTUREq
five hundrednsowner an(ep. NEW RESIDENTIAL ELEC7R SQFC. STORIES 5 ❑I,tier owner.(the property,or my employees with wage a.their sale TYPE CONSTRUCTION
mmpensatim,wBldothe work,And thealructum ts not Intended or offered for
F❑ sale(Sec 7014,Budnes.and Professions Code The Contract.?.LIcense Lw
5R$ damn[apply to en owner of property,who builds or improves thereon,and
wh..such work himself or through his own employees,provided that such OCC. RES.UNITS
improv tramsarenot Intended proffered f.rsale.IL however,thebuildingor TOTAL:
Improvement usoldmthn.neyearofmmpietW%theowner-bu0derwRlhave
tkLtfurden of proAng that he did nm build or lm rove for ofwle.). 4
LU P Purpose Qrr.'_u'w`�.'i PI:U1NBI7alCPEl2MIT "�'t.c' i'e,1:;FEE";.[;;ROUP
7ANE APN
L as owner of the property,Am exclusively contraNng with licensed PERMIT ISSUANCE / t•
mntractors construe the cotthe project(Sec 014,Business and Professions Code:
The Conten ors License law don nm apply to se owner of property who ALTER-DRAIN&VENT-WATER�A)
Wilds or Improves Nerem, and who contracts fee such, plojem wtth a _
agBj(actor(s)licensed pursuant to the Contractors License Law. L:';,'i:FEE'SUMMARYp:. 7'.
LJ I am emmpt under See B&P C for this recon BACK FLAW PROTECT.DEVICE -
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N
WORKMAN COMPENSATION RECEIPT a
❑1 h.reby affirm that I have a certi0ote of consent to self-Wure,or FDCTU ES PER TRAP SCHOOL TAX Y— N
certificate of Workers'Computtand.Insurance ora certified copy thereof(Sec. RECEIPT I
38W Lab C) GAS E.A.SYSTEM-1 ING4 OUTLM PARK FEE Y N
Policy• RECEIPT N
m any GAS PA.SYSTEM-0VER4(FA)fqikr. BUILDING DIVISION FEES
rtBred copy is hereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
� Certified copy u filed withh the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE ARY-STORM F.A.700FI Date Recei t#
Rhil.clion need not be completed U the permit b for one hundred dollars
($100)Inertlem.) Le WATER BEATER W/VENT/ELECTR ENERGYFEE Y N
Illnoy thatoy an Peron nce Intr thewmk so Ast hecom rmit subjeclssued, —
I shall not employ any person In any manner at n to become subject to the
W WATM SYSTEM/TREATING
Applicant Compensation laws o(GlUomb.Dale PAID
_ � NOTICE TO APPLICANT-. Biter making this CertBlate of Fiempllon,you �w RESIDENTIAL PLMB. SQFT. Daft Recei t#
Nwld become subject to the Workers'Campensatbn proal Ions o(tM1e Labor TOTAL:
N Code,you=at forthwith comply with such provislans or this permit shall be U
j deemed revoked.
c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there b•mfom.mtruction lending agency for the perELECTRIC F
Z Ince of the work for which this permit Is Lasted(See.3097,Civ.CJ �� EE
O Lender's Name - ,,;, .- PLUMBING FEE
WH Iandtea Address qN. ;*Y".ci{MECI-IANICAL-PERMIT• ', FEE?-" MECHANICAL FEE
1certifythatl have read thtsappBotionand statethatthe above information
Iacorrea.lagreetocumplywlthaHdtyandoauntyoedlnanresandptelawa PERMIT ISSUANCE FEES PAID.
W relating to building onestmction,and hereby authorlre representatives of this
- Z tlty to enter upon the abovo-nentio property for
Wpectbn purposes. ALTER OR ADD TO MECH.
— (We)agree to unser,Indemrd n d ep harMem the Clty of Cupertino Date Recei t#
.gaWt Babilities judgments, odes rases Ichmbylnmywayaccrue AIR HANDLING UNIT OPO MID)CFM)
.g.instaad Ci Inco the SUBTOTAL:
sego gr ming this ps
AIR I-v.NDUNc uNrr(OVER la,DDOCFM) CONSTRUCTION TAX
Ignature WApplicant/Contractor Date EXHAUSTHOOD(W/DUC'D CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WllltheappBant or future building occupant store or handle hazardous BEATING UNIT CM 107,000 BTU) Date Recei t#
material as defined by the Cupertino Muninpal Code,Chapter 9.12,and the
lie.lth and Safety Cade Section Z5532(a)1 HEATING UNIT(OVER 100,000 BTU) TOTAL.
11Yes , MN.
Will the applicant-rfumre building ompmt use equipment or devim VENTILATION FAN 6INGLE RFSID) ISSUANCE DATE
which emit lumedcus air m'bmbuntsas defined bythc Bay Area Air n /K 1
Quality Management DLstHtll BOILM-COMP OFNOR 100,0(D BTU) r D
4Yes MN.
have read the haeaBus materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) DEC 11
the Calilamn Health&Safety Code SWiom25SM,25533and75534.1 ���
understand that If theWilding does em currently have.tenant,that itis my NEW RESIDENTIAL MECH. SQ.ET
raporuibility to notify the occupant of the requtrements which most W met
prior to Issuance of.Certificate of Decupancy. CITY f CUP
tIi I IIVVv
Owner or authorized agent Dae
ISSUED BY:
TOTAL:
OFFICE COPY