23431 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro ed Identification PERMITNO.
Bulldlr§Address:
! cal-IAoG�tECz� � Lti, 1 2343
nare arse: /L one:
G 'I —2tfU� CITY OF CUPERTINO-BUILDING DIVISION
cm"•tlar•N•m•, - LmNo: APPLICATION I PERMIT
1
G •� DC—K' 15��b T�y3 BUILDINGELECnUCALPLUMBINGMECHAMCAL CATEGORY CONTROL N
Architect/Engines. T I - s 1 Lie No: - '
II
QTr ELECTRIC PERMIT FEE BUILDING PERMITINFO
Addms - �_
LICENSED CONTRACTOR'S DECLARATION PERMITISSUANCE
sed
er
Ihereby
di..7000) (Dim,1 3.fthe Businessand of Cssions9(mmmrno APPLIANCES-RESIDENTIALingwir� �+105 DESCRIPTION
lift..h I.fm 7000)And Affect.
the Budnessand Pro(efalmeCode,and my 1 1l /1 CEJ�sA
Llcensels In full((yam andLieN -J PANELS 1 1 �f�pP«at1J
Date —�•—Cont clue IEW, UP TO200AMPS
ARCHITECT'S DECLARATION 70I-1000 AMPS
w0❑76C I understand my phm shallbe used As public records. OVER 1000 AMI'g 00' S/SQ.FT.
k UZ tj Licensed Professbnsl SIGNSELECTRICALFIMA - ED
<<<QLLRR�u y OWNBR-BUILptDER DECLARATION SPECIALCRtCUIT/MISC
2 Ihereb a(Rrmthetiam axem (mmthe CoMraaor'a Llcenaehw(or the
❑❑ lo5owing reason.(Section 7m1S,Buelne®and Pm(eviona Code:M tl or
F , cauntywhichrequr apemdttomrat Malter,Impmv de=lbh,ormpar TIME METER OR POLE INST. /
3 anytmctum pdortolb Issuance,also requiresthe applicant for per utto D TE
Ole a signed statement that he Is licensed pursuant to the provIslms of the POWER DEVICES
0 re
Contactor'.License Isw(Chapter (commencing with Section 7000)of Divi-
SWIMMING�n tSWIMMING POOL ELECTRIC
COQ slon3ofthe Butlnasmd Professions Code)orlhat befeexemptlhertfromand VALUATIOtJW
a.a the basis for the alleged exemption, Any violation of Section 7131S by any OUTLE•I.SSWI.fC}iFSFIX'C1713P5 I 2 lox) wW6. G.V I
OA
Applicant fora perenk sobjectsthe applicant to a civil penalty of not mme than
R O5undred dollars MOT, NEWRESTDENTIALELECTR
�n I,as owner of the property,or my employees with wages As their sole STORIES TYPE CONSTRUCTION
monpeneatim,will do the."Ad thestructure Isnot Intended or offered for
O sats(See 7044,Bu.tu... nd ProfessionsCode:The Contractee License Law ED 1Pj
(:rl does not apply to an owner of property who builds or improves therrory and (�, C. .R ' RFS UNITS
CC who does such work Morselforthrmgh Mown employees,provided that such - o
improvements arc not Intended oroffered for sale.If,however,the building or
improvemcntbsoldwlthinoneyearofcompletbrytheowner-bullderMIthave j
tl(,jZurden ofpmvingthat he did nM build or improve forpurpmeofsate.). QTY. PLUMBING PERMIT AT -E
u L as owner of the property,am exclusively contracting with licensed AP
contractors to construct the pmject(Sec.7Ud,Business and Professions;Code: ' PERMIT ISSUANCE '� J
The Contractors License Law does not apply/o an owner of property whoJ'
Wilds or i.p.thereon, and who contracts for such pty"with a AL1FR'ORAIN&VEM-WATER(FA)
ftaip.cior(s)licensed pursuant to the Contraeols License Law. FEE SUMMARY
LJ I am exempt under See B k P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS FLDOR ROOF,AREA,COND. SANITARY - Y. N
Owner Date RFLEE'f M
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N
❑1 hereby affirm that I have• Insurance
of consent to o self-insure,ora RECEIPT N
certiflestea(Worken'Compensation lnsuranaara certified copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FTE Y N
3800,Ub CJ RFCERT M
Policy N GAS EA.SYSTEM-OVER 41EA)
Com any BUILDING DIVISION FEES
C�CenlMd copy Is hereby famished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
L�-J•T`eni0ed ropy Is filed with the city inspection dlvWm.
CERTIFICATE OF EXEM PTION FROM WORK ERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SAMTARY STORM EA 700FT Date Recei tit
(Thl•vectlon need net be completed if the permit Is forum hundred dollars
ISIM)mley') wnrFR HEATER w/vENT/FLECTR ENERGY FEE Y N
l eertifythat in the periormanceof the work forwhich this permit le Issued,
I shall not employ any person In any manner so As to become subject to the WATER SYSTEM/TRIATING
Workers Compensatfonlawauf Callfomb.Date PAID
—
Applicant Q Applicant NEW RESIDENTIAL PLMB. SQYr. Date Recei tN
Z G NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
}_ should become subject to the Workers'Compensation provisions of the Labor TOTAL:
U) Code,you=at forthwith comply with•uch provisions orthh permitshallbe BUILDING
j dmrred revoked.
ttl G CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Ihembyaffir hat there Is a construction lending agency for the perform T ELECTRIC FEE
it 61,
Z ameoftheworkfor whish this permit Is issued(Bee 3097,Civ.C.)
C.) 2 Lender.N.me PLUMBING FEE
IL F Lendcr'.Addm. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
W rr
I mrtify that l have read this application and sate that formation
O
6 Iscoect.lagmwmmplywlth&Hcityandmunlyordlnanmand Wtelawe PERMIT ISSUANCE t '� - FEES PAID:
r relating to building conshuction,and hereb rizerepresentative•of this
N
F Z city to enter upon the abov=418ne pe, forlespecilonpurpsers. ALTERORADDTOMECH. Date Racal IN
(We)e to ssv Indemolya ice harmiess the Clty of Cupertbo
V against IIIOes,jadgme ,cosea d non which rnayln anywayacorue AIR HANDLING UNIT Q010,ODo CFM) SUBTOTAL:
ag.1cA 1 .ty In con of granting of thh pemdt.
2tl AIR HANDLING UNIT(OVER ID,DDocrM) CONSTRUCTION TAX
,gllin reof Ap c nm Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAIR OUS MATERIALS DISCLOSURE
Will the applies or a tore building occupantstore or ha nd le havardous HEATING UNIT(10 IOD,ODO BM
mDate Revel HI
material as dell ned WCupertim Municipal Code,Chapter 9.17,and the
Health and SafetyeSaction75537W7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
F7 Yea {+� No
Will the Applicant or NNre building occupant use equipment or devices VENTILATION FAN(SWCLE RFSID) ISSUANCE DATE
which emit hazardous air contaminants as defined bythe Bay Area Air
Quality Management District? - 'BOILFR(AMP OIIs OR IOO,IXp BTU) PAID .
Yen No
have read the hazy ousmaterial,requirements under Chapter6.95 of BOIER-COMP(OVER 100,000 BTU)
the California IIM allh&Safety Code,Sections 75505,75533 and 75534.1 NIAR 20
understand that if the building does ncurrently have a tenant,that it is my NEWRFSIDENIIALMECH. SQET 1992
responsibility to nes ify the occupant of the requirements which must be Bret - /x
prior to Issuance of a Certificate of Occupa my. V ITNY\UI-F�CUYCfI I I... {{y
Owner or authorized agent
Data ISSUED Tnx
OFFICE COPY