20161 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PEIt TNO.
Budding AddAddress:anD vm�GS 20161
wnera ame: L one.
CITY OF CUPER11NO-BUILDING DIVISION
C:; ors Name: Lk.No: APPLICATION / PERMIT —/9— 90
ArchlteC nee 9 BUILDINGELECnUCALPLUMBINGMECHAMCAL CATEGORY CONTROL N
!p Lk.Na
QTY ELECTRICPERMIT FEE BUILDING PERMITINFO
Address: PERMITISSUANCE ❑ 1:1 El
CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions o(CM1apter 9(rommene APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwith Section 7000)of Dlvlslon3oftheB"tl and ProfntlonsCodgandm
license is in(uJJ��in daffect. PANELS
License Chm Lk.x 076-5 749 c
Date Contractor
ARCHITECT'S DECLARATION 701-1000 AMPS
90 2 I understand my plum ahaB be used u public racordm OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
Licensed Professional SIGNS ELECTRICAL
<«< OWNER-BUILDER DE
{"n SPECIAL CIRCUIT/MISC
Z p., [hereby afN DECLARATION.(S dlunexempHro ossa d Professions
License law tort he
following reamn.(Section 70315,Business and r, fp l n, Code:My city it
TEMP.METIR ORPOLE[NST. '
K,� muntywhimprc toimb ime,- l-q- lth..pmvgdemo0ah,orr tic
q any ataaturc tatements has a I.licensed pn num(t the provisions
of tic POWER DEVICES
Nle a signed statement that he b licensed pursuant to the provleiom of Me
Qb3O COntradorb License Law(Chapter 9(commencing with Section 7000)of Dlvl- SWIMMING POOL ELECTRIC
I. Won ofthe Business and Pro(miov Code)mthat he is exempt therefrom and VALUATION
4 O the basis for the alleged exemption. Any violation of Section 7011.5 by any OUTLE•ISSWITCI lESFIXTURES �
applicant for a permit ab*U the applicant to a civil penalty of not more then r •v
$
five hundred as owner ars ofthe pro lod NEW RESIDENTIAL ELECTR SQFC. Wm TYPE CONSTRUCTION
�O �I,asownerof theproperty,orhe employeswith wages rtheir sale
me Ike.7 KBuldothe essand k,endthes Code: heis m IntendedContractor License
for
Law
O axle not apply
to an owner
d Professions who
build,or impctofs he me law
$ does not loan owner olproperty ghhisonempor improvnthercoryuch OCC.CROUP RIB.UMTS
who
provemmu,amk intenlf ded
oroughedfor owne.If,ho n,er,theprovided ildingh
improvement issold ithinone earofcomplaale.th mwer-hNebuRdl have TOTAL:
improvement is sold withinoneyearo(complNkrytheowner-bullderwlll have
tlAkurdan of proving that he did not build or Improve for purpose of axle.). QTy. PLUMBIN ERMIT FEE FLOOD ZONE APN
"L as owner of the property,am exclusively mntratting withI—a—
rop(MI.I.LSSU CE
ntractom to construct the project(Sec.7044,Business Professions Code:
The Cmumd is Llcenm.Iaw don eat apply to an owner of property who LTER-DRAT
it builds or improve thereon,and who contracts for such pkajeda with e
oBliacior(s)licensed pursuant to the Contnttoe.License Lew. BACK OTCCT E FEE SUMMARY
LI I em exempt under Sec. B k P C for this mann
Owner Date SFLUORR F,AREA, SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RECEIPT tl
❑I hereby affirm that I have a certificate of consent to eel(-Inare,ora
/ SC:HOOLTAX Y_ N
3800 Laic o(Workers'ComperuaHon I�munnce oranrtlfled copythereol�ec.
RECEIPT tl
3800,Isis CJ CAS FA. 1 O PARK FEE Y_ N_
Paltryp ///L� >t?Q(o 7^lG DING DIVISION
Co any .j r�r�J��p GAS EA. VER4(EA)
/O/IL QTfC LT BUILDING DI VISION FEES
�CertHled py V hereby hthe tlty furnished.
�G nHled espy b filed with the city Inspection division. GREASE/IND WASTE INTFRC 7PTOR PLANCHECK FEE
CERTIFICATE OF FREMPTION FROM WOR KERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date RCLrei t#
(This section need not be completed If the permit Isfw One hundred dollars
(4100)otifyth WATER HEATER W/VENT/EI CTR ENERGY FEE Y _ N
I certify that o they person
any
m workan a to b this a permit b Weed,
I shall not employ any person In any manner m u to became subject to the WATER SYSTEM/TREATING
Workers'Compeneatlon laws O(GII(umA.Data PAID
ZZ Applicant
O NOTICE 70 APPLICAM:$elver making this Certificate ml Exemption,you NEW RESIDENTIAL PLMB. SQFf. Date Recef tl7
Hshould became subject to the Worked CompewHon provisions ofthe Labor TOTAL:
M N Code,you=at forthwith comply with such provisions orlbb permit shall be BUILDING t.CV
W j deemed revoked.
a c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby WE hat there lea construction lending agency forthe perform- ELECTRIC FEE
D Z arm olthe work(or which this permit b Issued(Sec.3097,Cls.C.) TOTAL:
0O Lander'.Name PLUMBING FEE
LL-I- Lendee.Addmm QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertilythatl have read thbapplicatkn and statethatthcabovelnformatlon
1 isrorrect.lagmtocomplywilh allcityand mce
untyorllnansand statelaws PERMIT ISSUANCE FEES PAID:
>. relating to building construction,and hereby authorlae repressmative..fthis
F Z city to enterupon the above-mentlomd Property for Inspection purposes. ALTER ORADDTO MECH.
— (We)agree to save,indemnity an d keep harmless the City of Cupertino Date Receipt#
against liabilities,jsdgmenls,costs and expeassawhich may In anywayaccrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against�said
�City in consequence of�the/grant ing of this permit. AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
- "-'�—
a.�lo�XJ ��9 9�
Signature of Appllcan ntrect.T Date FRHAIIs'THOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willtheapplicarat or future building occupant store or hand Is hamnims HEATING UNIT(TO l 00,ODO BM Date RCCCI the
maerial as deBsmd by the Cupertino Municipal Code,Chapter 9.17,and the
I Ieallh and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BM TOTAL: l
qISSUyes ,I+�—,No
llthe applice for future bullding occupant use equipment or device VENTILATION FAN(SINGLE RFSIDI
AN(F TEE
which emit ham rdous air meta minants as defined by the Bay Area Air 11ss,�j
Quality Management District? BOILER-COMP OHP OR 100,000 BTU) -
Yc. ❑n Na
v.mi.Healthe h
hamMaus mode,Se tions 25505,255 3aC 2SS34A95 of BOILER-COMP(OVER 100,000 BTU) (�
the Gllfomla HealtF kSafety Code,Sections 15505,75533 and 75534.1
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT
responsibility to notify the occupant of the mqulrements which must be met Cltg Of rB(1P.a
pd Wuance ofaCertlflcate Of "parry. a7• ,IInO
�19 5v
Uwner or authceimd agent Date -
TOTAL: ISSUED BY:
OFFICE COPY