23988 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification I PERMITNO.
riding Address: q,"7 C,oAbIle-wood 23988
T5Vnen. ante: yy��..�� eine:
t ie/ a[,( 'l S3. CITY OF CUPERTINO-BUILDING DIVISION
conte or I Name: �/. F/, Lic.No: APPLICATION I PERMIT
U,1�` • J 3?(7 liBUILDINGELECTRICAI PLUMBING-MECHAMCAL CATEGORY
Architect/Englneer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: - ' PERMITISSUANCE ��
LICENSEDCONTR under provisions
of Chapter
I hereby Sectiorst n
iv licensed ofthe underrprossaral offead.o Codemmec- APPLIANCESRESIDENCIAL JOB DESCRIPTION
inenseI in fon 7000)o(Division aftheBudnessand Pro(eulonsCade,and my /rL��l` Q•
Lim. ie Il(n;afs_uiRL(.o/r��y—°j-ann Licfect. S7 -7 - PANELS
Llcenae_-�C/ a - Lick .M _LUPT0
Date Detector
ARCHITECTS D LARATION 201-IODOAMPS
02• Iundentand my plans shallbe used as public records OVER IOW AMPS SQ.Fr.® IN
N` F/SQ FS
\I
Licensed Professional SIGNS ELFOTRIGL ..
�j OWNER-BUILDFA DECLARATION / \/� r— p�
5['ECULCIliCUIT MISC 11'L�. 1E••(a
zvl owing enrm Qutlameemptftte.a Contnciores Code:law tort he 1
o following reason.(Section 7m1.5,Buslnem and Isrofessbne Code:Any city or �
Wd 1EMP.METIRORI'OLE INST.
anystm lchpe tolap anct alwm-q imth apmvgdemol4M1,orrepto
any stmRure tatemente that
he 13 Imnse upummant to the pro aui ns of t e POWER DEVICES TE
file a signed kens statement that he t r 9(cont pursuant to the tion 70om of the
Ow son Sof the Bums Law(Chapter.(mde).,tngwlttexempn70W)ofDivl-
30 don3o(theBusineu and Profanloos Code)orthat M1ebexempt there(romand SWIMMING POOL ELECTRIC VALU00
TION
the basis for the alleged exemption. Any ,violation of Section 7011.5 by any
OS applicant for a permit subjectsthe applicant to a civil penalty of not more than I111'ETSSWIT12HES'FlXT[AtFS
five una ed owns of thepro SQ STORES TYPECONSTRUCTION
I,as owner of 1M1e property,or my employees with wages r their sole
NEW RESIDENTIAL ELFLTR EI.
comptior,willicess workfeslhestructurehrustIntended orofferedfor
q saleCZ-7044,Bualnow and Pmoperty Code:That orimp ciots License Law
$ doe notapply ta ansuchwrk owner ofpropertywho builds mpoyees,pvethereon,thatand OCC.GROUP RES.UNTTS
EE
who does
ments aorkhlmeelf ndedorwgh his own e,If,ho everthebuiilding r
improvements arenor intendedoroofc=fee sale.theo v.Wflderwgliove
Improvement bwW within ane yearefcwnpletbR the owner-W Bderwill have '
tElLjiurd an of proving that he did not build or Improve for purpose of sale.). CITY. PLUMBING PERMIT FEE . FLOOD ZONE APN
L as owner of the property,am exclusively contracting with licensed PFRMTI ISSUANCE
contractors to construct the project(See 7014,Business and Profeasiaru Code:
The Cortisone.License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(WWilds or Improve thereon, and who contra for such En,,"with a FEE SUMMARY
clNT+cior(s)Wersed punuant to the Conrado(.Lima.Law. BACK FLOW PROTECT.DEVICE
L j I am exempt under Sea B&P C for this reason
1-u ITIc.rin err.
Owner Date
DRAINS FLOOR ROOF,AREA,(OND. SANITARY Y_ N_ '
RECEIPT Y
WORKMAN COMPENSATbN DECLARATION
FD(TVRES PER TRAP �s SCHOOLTAX Y N
❑1 hereby a(flrm that I have o certificate of consent to op thereof
or RFOEBrT N
certificate o(Worken'Comperuallon Insurance ora certiMd mpythereo(�ec. GAS EA.SYSTEM-I INCA OUTLETS PARK FEE Y N
3RW,Lab C.)
Policy Y C RECEIPT
CAS FA.SYSTEM.OVER 4(FA)
Com any BUILDING DI VI NFGES
C Ified copy fumlehed. CREAsRANDUM!,WASTE INTERCEPTOR PLANCHECKyPFE .: >I �Q
aCerifled copy is filed with the city Inspection division. W I a
CERTIFICATE OF UMPTION FROM WORKERS' GREASE7RAP PAID
COMPENSATION INSURANCE $EWER-SANITARY-STORMG 200FT Dae R¢
(Thissectlon need nctbe completed Bthe permit bfm one hundred dollars
(fl W)eitifyth WATER HEATER W/VENT/ETECTR EN Y E Y IN 4
Irl see that emIn ploy
any person
uin annce manner se,as
to become
pesubjecrmit is Issued, /
I shall not employ any person In any mannerse,u to become eubkct to the WATER SYSTEM/TREATING
Worken'Compensation haus of California.Date PAID �/11
Z Applicant NEW RESIDENTIAL PLMEL_SQFT. Date 7CV1
Z O NOTICETO APPLICANT;R,aner makingthis Certlflote of Exemption,you
should become subject to the Workers'Compensation-I'Of mof the Labor OTAL:
~ N Code,you most fort hwlth comply with such provisions or this permit shall be
W j deemed revoked. B DN
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL I hereby affirmthat there b a construction lending agency for the perforrry ELECTRIC FEE
� Z ance of the workfor which this,permit Is hatted(Set.3097,Cls.C.I
Pi
U O Lender's Name i - PLUMBING FEE
H lenders Address // QTY. MECHANICAL PERMIT FEE
O W ImAifylhatlhavemadthbapphmbonanddatethattheabove informatim, MECHANICAL FEE
1 Ifrormat.I agree to comply with all cityand county ordinance and date laws PERMITISSUANCE ` �� FEES PAID:
(n relating to Wilding construction,and hembyauthorizerepmentatlyesofthb
F Z city to enter upon the abovo-mentioned property for Inspection purposes. ALTERORADDTOMECH. Date Recei tM
V — (We)agm to save,Ind emnfy an d keep harmless the City of Cu pen lno
against liabilities,Iidgments,cods and expense which may In any way accrue AIR HANDLMG UNIT(TO 10,000 CPM) SUBTOTAL'
at aaltl C' In conseq of the gran ng of this permit
AIR R HANDUNc UNIT(OVER lo,inocFM) CONSTRUCTION TAX
WA 77Signa of Appiim Con r Date. EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA USMAT RIALSDISCLOSURE
Will theapplicanlorfuture building occupant storeor handle hazardous HFATINGUMT(TOI00,00081T1) Date RCC¢t N
materiel as defined by the Cupertino Municipal Code,Chapter9.tj,and the -'
Ilealth and Safety Code Section 25532(a)2 HEATING UNIT(OVER 100,000 BTU) TOT
❑Ya No Wj
Will theappllcant or core building occupant use equipment or devices VWfILATION PAN(SINGLE REBID) ISSUANCE DATE
which emit hazardous air mntamiruntsas defined bythe Bay Area AU - k4�� pp
W
allty Management Districts BORER-COMP(3II'DR 100,000D BTBTU) it I
Ye n❑No
havcmxdthe harardouamaterialsrequiremenHunder Chapter6.95o( BOILER-COMP(OVIR100,000BTU)
the California Health&Safety Code,Sectiom 2550.5,2M3 and 25534.1 AUG 2 7 1`7912
undemmnd that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. 'sJ7
mporulbility to notify the occupant of the requirements which must be met .'
pdeirtolnu nce ofaCerificat eiforaupanry: CITY UP v 114U
or authodud ogee fly,Data ISSUEDBY
OFFICE COPY