23758 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERNEIT NO
.
BuBdingAdd resa: - - [,1 3.7 5 8
L,% LL CITY OF CUPERTINO-BUILDING DIVISION
^baQ\m o (Lk.Na: _ APPLICATION / PERMIT
`Tk co,r & C+--x" • 1'�K�+ BUILDING-FLECTRICAGPLUMBING-MECHANICAL CATEGORY , CONTROL if
Amhltect/Engineer. &, L15..P!q:!2 BUILDING PERMIT-INFO
S G `e- 0�dp``/(-f/-,�' QTY ELECTRIC PERMIT FEE
Address CONTRACTOR'S J'� pFRMITISSUANCE ❑ ❑
ZICENSEDensedoeepr DECLARATION
IhthSy ofirmthmlam Bcenaefthe B.provl..d Pa f.Chapter 9(mmmne APPLIANCESRE5IDENITAL JOB DESCR71'fION
ingwe is In fon force of d affean3of[he Buslaesand Pro(eseloneCade,and my
license lain fail force and c.# PANELS 1 '
Licens Class Lk.K
Date Contractor
ARCHITECPSDECLARATION 2014000 AMPS
q�q�vu 0 rOr.. !understand my plans shall be used s public records. OVER 1000 AMPS SQ.Ff: AR B .FT.
tt�Fi Licensed Professional SIGNSELECTRICAL -
<QQQ Q uuu�555 - OWNER-BUILDER DECLARATION
I-n '
[hereby offirm that lam exempt from the Contractors License law for the SPECIALCIRCUIT/MIEC_
O following reason.(Section 7011.5,Business and Professions Code:My city or 't
F E� county which requires.permit to on.tmdalter,mprmeem
,doltvh,^rrepalr
any TEMP.METER OR POLE[NST. -
.e stclure prior to its Issuance,also requres can
llthe applicant for such permit to
122
yy m
L5 file signed statement that he V licensed pursuant m POWER DEVICES
the provisions of the '
Wb Oµ Contractoh L1crosc Iaw(Chapter 9(commencing with Section 7000).f Divi-
`4, SWIMMING POOL ELECTRIC
30 eton3o(the Businesand PrdeslordCode)orthat hebexempttherefromand VALUATION
basisnt(ofor the alleged exemption. Any violation of Section 7031.5 by any OU METSSWITCHESFIXURES
appllar a permit subjecothe applicant to a civil penalty of nor more than
five hundred dollars($500).
r4, NEW RESIDENTIAL ELECTR SQ.FT. STORIES- TYPE CONSTRUCTION
❑I,as owner of the property,or my employees with In wage as their dole
compensation,wB,imessl do dPr and the structure Vnot
ontractortended aroffered for
q sale(Sec.7044,Buelras ami Professions Code:The Contractors Llceee Law _
$ does not apply to an owner of property who builds or improves thereon,and OCC,GROUP RES.UNITS
who doessuchworkhimselforthmwgh hlsownemployees,provided thatsuch
Improvements are not intended oroffered for sale.If,however,thebullding or TOTAL:
improvementimold mthinoneyearofcomplellon,theowner-budderwill have
trycjZa rden of proving that he did not build or Improve for purpose ofsale.). QTY 'PLUMBING PERMIT FEE FLOOD ZONEAPN
11 L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE �B
contractors to construct the project(Sec.7046,Business and Professions Code:
The Contractor's License Law don nor apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or Improve thereon,and who contracts for such projects with a FEE SUMMARY
cgBl{actor(e)Bcensd pursuant Ed the Contractor's Lkerue Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under See. B&P C for this reason
flITTeIrm Fens
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES,PER TRAP SCHOOL TAX' Y - N
[:If hereby Oftrm that I have a ar iRam of consent to self-inure,or.a _0 RECEIPT
certificate of Workem'Comperaatloo Laurance or a certified copythereuf(Sec.
3800,[ab CJ GAS EA.SYSTEM-1 INCA 0UTLET5 PARK FEE Y N
'RECEIPT p
Policy p GAS FA.SYSITbt-OVER 4(EA)
Com any . BUILDING DIVISION FEES
C. R d copy I.
hereby furnished. GREASE/NDUSIRL WASTE IN'T'ERCEPTOR PLANCHECK FEE '
C. Bled copy b filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-gANp1.AAY-S'NRM EA pOFT• Date Recei fN
(rhissection need not becompleted if the permit bfes one hundred dollars
($100)orles.) WATER HEATER W/VENP/FJ.ECTR ENERGYFEE Y_ N_
I mrtifythat to the performance of thework forwhlch this permit is issued, ,
I shall nm employ any poen in any manner eon to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID '.
0 Z Applicant NEW RESIDENTIAL PLMB. SQF7. , 'Date Recei t41
Z O NOTICE TO APPLICANT: making this Certificate o(Exemption,you
Fshould become subject to the Workers'Comperdatlon provblora of the Labor .. TOTAL:
W Code,you moat forthwith comply with such provisions or this Permit shall be BU NG
W > deemed revoked.
FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
IL Z I hereby afRrtn thatthereba construction lend Ing agency for the perform- TOTAL: -� ELECTRIC FEE
7 ance of the workfor which this permit b Isued(Sec.3097,Civ.C.)
V O Lenders Nature PLUMBING FEE .O
F Lendee.Addres QTY. . MECHANICAL PERMIT-.- FEE
O W . Irtifythat I have read this application and state that the above Information
FEE
ce
d Is eared.i agree to comply with all city and county ordinances and Aate laws PERMIT ISSUANCE" FEES PAID:'
>. 0. to bWlding construction,and hereby authorize representatives of this.
(.- Z : tltyto enter upon the above-mentioned property for inspection purpose, ALTER OR ADD TO MECH. Date R2Cfl tN
e)agre to save,Indemnify an d keep harmless the City of Cupertino
V agar Hia itck,odgmen , sande meeswhichmaylnanywayaccrue AIR HANDLING UNIT fro 101000 CFM) SUBTOTAL:
agar aai t mneeq a o(the gran oftMe permit -
I -�,;5 AIR HANDLING UNIT(OVER 10,m0CFM) CONSTRUCTION TAX
Si m.f Appllant/Contractor Date L EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Ill thea applicant or future building occupant stare or handle hazardous HEATING UNIT(T0100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.1$and the Date Recei tN
He.lth and Safety Code Section 75531(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: -0
❑ Yes MN.
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSIIVOATE
which soul haaardmes air contambdnts as defined by the Bay Area Air _ P {6y1
Quality Management District? BOILER-COMP(3FE'DR 100,000 BTU[
4nYea ❑❑No
haveread the bazallousmaterials requirements under Chapter 6.95of BOILER-COMP(OVER IID,ODOBTU) JUN -11992
the California Health&Safety Code,Sections 75505,25533 and 15534.1
understand that if the building doe.not currently have a tenant,that it is my' NEW RESIDENTIAL MECH. SQ.FF.
responsibility to notify the occupant of the requirements which must be crot C11Y Uf VUYtMlIIV1J
pri^r to isuanm'M a Cedifkate of Ocmpanc'. ,
Owner.,authorlzed.gent Date TOTAL ISSUED BY:
OFFICE COPY