24407 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identlfleatinn PEILWT Nva 4 4 0 7
Buuding Addresa: Z
2 1 ��txtnAe, �"�- sitict
a anr: hone: q
7 U CITY OF CUPERTIN6BUILDING DIVISION
Con, dor.. ;A �I �,mrN,y APPLICATION I PERMIT D. — Z
• l� C7 BUILDINGELFJCTR(CALPLUMB�MEC MCAL CA RY CONTROL N
Architect/Engineer. Lk No:
1� BUILDING PERMIT INFO
�0�` ��l)4Aa3W QTY ELECTRIC PER FEE
Add A PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby sffho,that lam licensed under provisions ofChapter9(comm®c APPLIANCF4 E L JOB DESCRIPTION
Ingwilh Secdon7000)a(DIWNon3o(the BuBlmsand ProfeesianaCodq and my
Bttnxlslnfuu 1 Lkd d. est PANELS A e nl pe
License Clam ^' LIa.N�
Date GOMndor
ARCHITECPS DECLARATION 1-
IQ+�aOzp I understand my plane shall be used Be public B. AM fL E� $/SQ'ET'
E� Licensed Professional SIGNS EL C L
6 OWNER-BUILDER DECLARATION PECIAL T/MW
z l., ?; Iherebya(flrm thatlam ezempt(mmthe Cantractora License lAw(or the
pp Ffollowing reason.(SMion 70315,Buslnero and Professions Code:Any dty or z � TEMP. ORPOLE INST.
mntywhirh reior In its pertmtto also alte�
apmvent forsbh,ortoDA
qq any atmcned statement
t that
he I,also sed pursuant
t the provisions
ofpermit e (OWER DEVICES
file a signed&cement that he a BoenxN pursuant it the proWkro of the
W w� Con3 of theLkeme Law ndProfpter9(commendng with xection 7")rnpttherefo(Dlvl- SWIMMING POOL ELECTRICM. VALUATION
�0� the b of the elle e d ProfemiamCode)violation oseection 03IS by any
0 the basis for the alleged jeers th.. My violation of Section 76)15 re any OUILE155WITCI IESAXTURFS / / 7 71
appBcentfor a permit subjects the applkanttoadvil penalty of not mnrethan e C L-(�
five undred dollars($SM. SQ MILIES TYPE CONSTRUCTION
z NEW RESIDENTIAL ELECTR .Ff.
z�n I,at,owner of the property,or he employees in with wages a IMe sole
compensation,0K Business,
uldothe work,and constructure a not Intended-act.e or offend for
osae(Sec 7614,Bus owner of
Prooperty Code:The Comnctora License Law
(� $ does not ue'sucyloan owner ofpmpertywho mbuilds
employees,
mplrlmpmovided thatandwhodsuch — OCC.GROUP RFS.UNITS
C: I.Prowa e.ts swork Mmtendedlf orough hbowne.If,ho a however,
building
or
Improvement iarenot Intendedprofferedfor us.H,hmvoveg lkler ill have TOTAL:
improvement bwW wllhlnoneynro(cnnpldion,the owner-bu0derwill have
tfv,bunlm of proving that he did not build or improve for purpose of Bale.). QTY. PLUMBING PERMIT FEE
u L as owner of the property,am ezcludvely contracting with licensed FLOOD ZONE APN
PERMIT ISSUANCE
contractors to coratmct the project(Sm.7014,Business and Professions Code:
The Contractors License Law don not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or Improves thereon,and who contract, for such pipjeds with a FEE SUMMARY
cj5actor(s)Licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
LI I am exempt uMer Sec. B &P C for this reason
DRAINS FLOOR,RODF,AREA,COND. SANITARY Y N
.� Owner Date RECEITN
WORKMAN COMPENSATION DECLARATION FINIURE4 PER TRAP SCHOOLTAX Y N
❑I hereWW affirm that I have a certificate of consent to self-Insure,or a RFAE�I.N
3800,Laeo(Workers CompemHon lruurance oracemifkd copytoereo!(Seo. GAS EA.SYSIEH-1 INCA OUMM PARK FEE Y N
Polic I CJ RECEIPT p
Pollry N raGAS EA.SYSrFM-0VER 4(FA)
BUILDING
DIVISION FEESCoFeyfiedcopy a tehed.
CeAfiedmpy is
with tn,tlty,WpMlan division. CREASEANDUSTRL WASIE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OFU MPTION FROM WORKERS' CREASETRAP PAID
COMPENSATION INSURANCE SEIVF.R-SANITARY-STORM EA 200Ff Date RCeDI NI
(DuB aection need nut be completed dtha permit a tarots hundred dollars
ell ro)orless.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N q /�
I mdlfy that In the performance of the work for which this permit is blued, 3.
I shall not employ any person In any manner so as to E. to the WATER SYSTEM/TREATING
WorkeWC tlo Laws of Qayfy�r�i; Data �Q � PAID
0 Z ApplicantNOTICE Uf/IfICAs.1 'Riate NEW RESIDENTIAL PLMB. SQ.FT. Date Revel of
Z O NOTICETOIris LICANT:ll,a er makingthis
pro ofExemption,off he
should become subject to the Workeri Compensation provisions o(the Labor TOTAL:
(q Code,you most forthwith comply with such provisions orlhe permit&hall be 13UI
LDING FEE
W > deemed revoked.
G CONSTRUCTION LENDING AGENCY SEISMIC FEE
1
I herebyatfirmthat there bammtmcdon lendingagenry forthe perform TOTAL: ELECFRIC FEE
D Z ance ofthe work forwhlchthe permit abased eke 3W7,CIv.C.)
U O Lender's Name PLUMBING FEE
U. Lendcr'BAddreae QTY. MECHANICAL PERMIT FEE MECHANICALFEE
OW Icertify thall have read theapplintenand katelhat theabove information
IL Tscorrect,lagreetocomply ithalldtya otyoctinanon and pate laws PERMIT ISSUANCE FEES PAID:
>. W nelatingtobullding t on authorize representatives ofth]
H Z dty to enc o ntlan m rW npurposn. ALTER OR ADD 70 MECH. Date Recei tF
u emrdty dkeep ha ent Ity of Cupertino P
V In g saM expen which ylnanywayaccrue MRHANDIINGUNrr ITOlO,OWCFM) SUBTOTAL; 2-3
CI eonBequ u, tM an
gofth pemait.
AIR HANDWNG UNIT(OVER 10,000CFM) CONSTRUCTION TAX
SlgmNreo ppinnt/C Date EXHAUST HOOD(W/DUC) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WWthe appllnnt ortuWrebuOdingompant emre ar laMle hazardom HEATING UNIT(TO 100,000 BTU) Date Recei to
material as defined by Me Cupertino Municipal Cade,Chapter 9.1 2,and the
10 Vend Safety Cod rte SSleumB 25532(a)7 HEATING UNIT(OVER IDO,000 BTU) TOTAL:
N.
Will the applicant crrture building occupant use equipment or devices VENTIATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardousalt contaminants as dented by the Bay Area Ab pp
- Quality Management District? BOdLR-COMP pFNDR 100,000 BTU) PAID
Yes No
have read the haze pus materials requirement,under Chap(er6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health&Safety Code,Sections 75505,25533 and 25534. 1 OCT 28 1992
understand that lithe bultdingdoes not currently have a tenant,that It is my NEW RESIDENTIAL MECH SQ.FT
responsibility to notify the occupant of the requirements which must be met
prior to issua nco of a Certificate of Om pa ncy. _ '�`I h/IA urs VUYC�r'I lllllu
Owner or authorized agent Date ISSUED BI' ./ 1 YayyLu
TOTAL;
OFFICE COPY