23530 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pmed Idx.tflastlon PERMIT NO.
Building (o7,: c2GS7L_1Nc 23530
wners aces: one:
CITY OF CUPERTINO-BUILDING DIVISION
. contra o shame: Lie.No: APPLICATION I PERMIT l —1
2 BUILDINGELECTRICAI PLUMBING-MECHANICAL CATEGORY CONTROL I
Arcbltect/Engimer. Lic.No:
,QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address
PERMITISSUANCE O El 0
LICENSED CONTRACTOR'S DECLARATION
Ihehsydi. 7000)tfamlicensed under sim3.fh.B.W ...d .fC .ter9(comman APPLIANCES-RESIDENTIAL - - IOgD ON
l�gmttime.h .full I..anDlvfect. fthe Bualn.sandTamoteWonaCode,end rrry f4IL`TI►�J`
license le In(u8 farce and effect PANELS
License Clan Lk.Y ^
Date Contractor '"
ARCHITECTS DECLARATION 201-IDOOAMPS
mOZ Iunderstand my pkmre
vhall be used as public cords. OVERIOOOAMPS - SQ.FT.FLOORARrA $/SQ.FT.
O
ULicensed Professional NISIGNSRLECTW�LTWI L _
OWNER-BUILDER DECLARATION� RC AT/MISC7t. I harebyaf(Irm that l ace exempt from the Contractor)Llrenx law fm thep following mason.(Section70)1.5,Business and Professions Code:Any city orPgtcounlywhichmquimsapermittommtmdalter,impmvedemolbh,orrepalr 'CO 'MISqO n anytructum Prbrt°Itsbuanceabo mcffiesthe applicant fmsuch pereettoVICES �6 O5file a signed statement that he b licensed pungent to the provisions of the3Contractees License Law(Chapter9(commencing with Section 7f100)of Dlvl- TOOL ECHLQl VALUATION
Yon3oftheBuslnanand ProfesslomCode)orththebexmptthemfmmand ��the Wab for the alleged exemption. Any violation of Section 7031.5 by anyWITCHESFIXTURE5applicant fora permit sub)ects the applicant to a civil penalty of not more than
five hundred dolkn(SSM. SQ}7, SIOWCS TYPE CON5IRUCTION
01,as owner of the property,or my employe.with wages as their wk [NTIAL ELECTR
compensallon,wllldothework,andthe structureb not intended or offamd for
C O rale(Sec.7094,Businessand Profnsiona Code:The Contractors License law
$ does not apply to an owner of property who Wilds or improvxg thereon,and .00C.GROUP RIS.UNITS
who d...ch work himseltorthr9ugh hlsown employees,provided that such
Improvements are cwt intended or offered for sale.If,however,the building or TOTAL:
Improvementbsold within°myearofmmplei Ntheowner-bu0derwBl have
ftuMen of pneving that he didrwt build or lmprove(or purpose of sale.). QTY, PLUMBING PERMIT FEE
LJ L as owner of the property,am exclusively contracting with licenced FLOOD ZONE APN
contmetore to construct the project(Sec.7044 Business and Professions Code: PERMIT ISSUANCE
The Contractor's Llcenx law does not apply to an owner of property who ALTER-DRAIN&VENT-
' builds or Improves thereon, and who contracts for such plojeRe with a WATER(EA)
cga�{actm(U licensed pursuant to the Contnctoes License Law. FEE SUMMARY
t_71 sen exempt under Sec B&P C for this reason BACK FLOW PROTECT.DEVICE
OUTSI DE DRAINS FLOOR ROOF,AREA,COND. SANITARY Y - N_�
Owner Date RECEIPT Y
WORKMAN COMPENSATION DECLARATION FD(TURES.PER TRAP SCHOOLTAX Y N
[hereby affirm that I have•certlfiae of a un fi m copy thereof
ora RECEIPT Y
locate of Worken'Compematlonlmunnce ora mrtl(kd upythereof(Sec. GAS EA.SYS7EM-1 INCA OUTLETS PARK FEE Y N
3800.Lab C.7 Q�9,6s tee/ RECEIPT If
Pollgp 7 GAS EA.SYSTEM-0VER4(EA)
Ca������mppppppenv — BUILDING DIVISION FCfS
9-CediOed copy b berebytumWed' GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CerilOed ropy b filed with led city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SAM•I•ARY-STORM EA 200E1. Date Recei t#
(This section need not be completed Bien permit b for one hundmd dollen
(SIfI mitifk m
ess.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
LM(y that the per(ounceof the work farwpermitIssued,,ch this permit la ed,
I shag not employ any person In any manner an as to become,abject to the WATERSYSTEM/TREATING
Work.i Corepensatlon lawsof California.Data PAID
-
0 Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Recei t#
Z O NOTICETO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation pravbiom of the Labor TOTAL:
a. fn
Code,you must forthwith comply with such provbiom or this permit shall be BUL �s
W > deemed revoked.
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE L SO
Iherebyaffimntu
hat there ba corutroctlon Lend kg agency for the perform TOTAL: ELECTRIC FEE
D Z aomofthework(or which this permit is Ised(5ee3097,CIV.C.)
02 landeenName - PLUMBING FEE
LL Lender's Address QTY. MECHANICAL PERMIT FEE
O W Iririify that I haveread thbapp0mtloh and statethatthe above informationMECHANICAL FEE
CL bmrraW.Iagree to complywlth all city and county ordinances and Yate laws PERMIT ISSUANCE FEES PAID:
>- W retaiingto building construction,and hereby authorize repeasentatN.of this
F city to enter upon the above-mentioned property for Impaction purposes. ALTERORADDTOMECH.
? (We)agree to save,indemnify an d keep harrNesa the City of Cu Persian Date Receipt#
V against liabilities,jdgmenb,costs and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
gai Id City In cony m of the granting of reds permit.
a mp�s ' „cya� 9'E_4.2 aRrIANDUNG UNIT(OVER la,000cFM) CONSTRUCTION TAX
Signature of Inset/Co�ctm Data EXHAUSTHOODCW/DUCT) CONSTRUCTION TAX PAID:
NAZAA US MATERIALS DISCLOSURE
Will the applicant or n building occupant store or handle hazardous HEATING UMT(TO100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Healthand SafetyCade Sectlon25532(s)2 HEATING UNIT(OVER 100,000 BTU) ' TOTA
QYea No
Will the applicant Mrs building occupant use equipment or devices VENTILATIONFAN(5INGLE RESID) ISSUANCE DATE
which emit hazardous air rontamlmnb as defined by the Bay Area AU
Quality Management Dutrict2 BOILER-COMP OHPOR 100,000 BTI))
4Y,a ❑No PAI D
havercadthe halemousmrieriabrequirements under Chapter 6.95of BOILER-COMP(OVER 100,000 BTU)
the GlBerets Health&Safety Code,Sections 25505,25533 and 25534.I
understand that if the building does not urmntly have a tenant,that it is my NEW RESIDENTIAL MECH. SQFT' APR 1 ? 1992
responsibility to notify the occupant of the requirements which must be met fYv 1
prior to Issuance of a Certificate of Ocu panty.
Ower or authorized agent Data ISSIUED BY: ITV V s
TOTAL:
OFFICE COPY