23456 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
BulW leg Address:
'��` it���, o3ca,�����,.,��aaQuo .'23.456
Ci t'ra K�%L1v7iWV J CITY OF CUPERTINO-BUILDING DIVISION
nsre a one: _l
Contiadgr'a Na� �u`, nvPI,- - Lie.No: APPLICATION/ PERMIT
Artistes sate/��En�rVVglwneer. BUILDINGELECTRICALpbDMB1 G HANICAL. CATEGORY CO
% QTY ELECT ICP IT FEE BUILDING PERMIT INFO
Add
PERhBTISSUANCE N
LICENSED CONTRACTOR'S DECLARATION LO
I hereby affirm tlutlam licensed under prwklons o(Chapter9(mmmemc- APPLIANCES" L OB DESCRIPTION
ingwith Section 7000)o(DiNdon3oftheauelnessand Pro(eselonsCade,and m 1.
nee b In(u0 and dfect. PANELS 1 a
.kenee C Llc tl S�S3 58 .,
ate Contactor 11k01AMPS
ARCHITECTS DECLARATION
q�q�uu mO Zp iundertand my pkwelaB be used sspubOcrecoNe. 1000AMPS SQ.Fr.FLOOR AREA $/SQ.Fr.
k Licensed Prafeasbnal - SIGNSE -
<�6 OWNER-BUILDER DECLARATION 7/MIST p�1
ZF•�7's lherebyaffirtnthallamexempttromthe Contractor's License law(r the AZEC
pp following reason.(Settles,7031.5,Business and Professions Code:Any sty or \ / p.�
p p fPoDMCES
OR POLE INST. ® t�l [� 9g••(l
cauntywhkh requires.perroft a mvgdemsuch,orm air L u u
q .c any atmdure priortostatement
that
he is licensed pursuant to the bnuchpeof permitto file a signed ebtement that he V r 9(cmn puruant to the proWsbm of theCotractorsWcemeLaw(Cha Pter9(commencing with Sectbn 7000)o(Dlvi- -Vtlon3oftheBusinmsandProfemiomCode)orthatheLsemmptthemfromand OL ELEC[RIC -DATE �.
<, the basis for the alleged exemption. Any violation of Smlon 7031.5 by any - SWITCHES
applicant fora permit subjects the applicant to a civil penalty of not mme than
five hundred dollars($50th.
[,as owner of the property, NEW RESIDENTIAL ELECTR SQ.R. STORIES TYPE CONSTRUCTION'
7< p ork,a or esemhure is employees r their
compensation,w0ldothe work and lo.Code:cium V not Intended License
c nseLfor
G dresnasle et appy to alnower ProkmbwhobuldsThe CImproves l.Imnaelad
who does
apply torn owner ofpropertyhisanemplrlmproveslhereoRand OCC.GROUP RES UNITS
whodoementsworkMmeelfedoor roagh his own formic.
If, owe provbeuildid that cath
(mp'rovemenb are not Intended orof(ered(ormk.l(however,lhebulWingor TOT t
ImprovementissoldwithinomyearofcomplMt Ntheawner-bullderwlllhave
tlI,llurden of proving that he did not bund or improve for purpose ofsakJ. QTY. PLUMBING PERMIT FEE
UU L as owner of the property,am excluelvety contracting with licensed FLOOD TONE "N-
ntractoatomnstruethe pmject(Ser.7064,Business and Professknseode: . PERMIT ISSUANCE
The Contractor's License Law does net apply to an owner of property who 1�-DRAIN&VENT-WATER(EA)
Wilds or imp on m thereeM and who contracts for such pLojects with a
t�W�acior(s)licerued punumt to the Contactr'a License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
IJI am exempt under See B &P C for this reason
s Avner Date DRAINS.FLCOR ROOF,AREA,COND. SANITARY Y_ N_
RECEIPT N
WORKMAN COMPENSATION DECLARATION
I hereby affirm that 1 have a mrtllicate of consent to self-Inure,or a TURFS PER TRAP �� SCHOOL TAX Y N
"rertlfiateofWorken'Comperuatlonlmumnmoracadif dmpythem f&n. RECEIFTM
3800;1.6C.) GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y_ N_
Po1ky N RIECEI'T p
Co nv GAS P.A.SYSTEM-OVER4(EA) BUILDING DIVISION FEES
Ned copy Is filed
the city CREASE/INIDUSTRL WASTE INTERCEPTOR PLAACHHCK FE
' CertNed espy Vfiled with the city inspection division.
t I CERTIFICATE OF EXEMPTION FROM WOR K ER SGREASE TRAP PA
' COMPENSATION INSURANCE SEWER-SANITARY-STORM EA MOFI. Dale RCCCI t#
1 (rhlssection need net becompleted litho permlt kforom hundred dollars
($100)orless') ENERGY FEE Y N
I=fy that In performance perfounce of the work forwhich m
thls pedt is Issued, WATER HEATER w/VENT/ELECTR
I aha 11 not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Worker'Compensation Laws of Califomk. Date PAID
licant
_Z p NOTICETO APPLICANT:IL after makingthIsCerti leateof Exemption,you NEW RESIDFNTTAL PLMB. SOFT. Date Recei t#
should become subject to the Workers'Comperuatlon provialonu of the Labor TOTAL'
p7) Code,you most forthwith comply with such provieium orthk permit shall be
deemed revoked. BUILDING FEE �e
ILC CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyaffir
mthat them is a construction lendingagenry for the pedorrry ELECTRIC FEE
Z ance of the work which this permit is Isued(Sec.3097,Civ.C,) T A t'
02 Lender.Naar PLUMBING FEE �-
LL F Lcodere Address QTY. MECHANICAL PERMIT S MECHANICAL FEB
OW 1cantl(ythst I havemad thlsappBatlonand statethat the abovelnformation
lIs correct.I agree to comply with a0 city and county ordinances and state laws � PERMIT ISSUANCE �� FEES PAID:
7. se
relating to bullding construction,a od hereby authorize representatives of this
Zcity to enter upon the above-mentioned property for inspection purposes. ALTORADDTOMECH. Date Recei t#
_ (We)agree to sive,Indemnify an d keep harmless the City of Cu pert los
ag bBltles,jud msnte Bend expenses which may In eny ayamue AIRHANDENCIINIT(TOI0,000CFM) SUBTOTAL:
Wt Id Clty a of the ming Is penntt.
n - AIR HANDONG APRT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor to EXHAUS'THOOD(W/DUCT) CONSTRUCTION TAX PAID: +U
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Revel
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Ekalth and SafetyCode Sedior 25532(.)7 HEATING UNIT(OVER 100,00D BTU) T
❑ Yes M No
Wlll the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined bythe Bay Area Air FF�� p pp��
QualityManagementDlstridt BOILER-COMP(3HPORIOO,DOOBTU) P A I Y
❑Yn. ❑No
Ihave read the hazardous materlala requirements under Chapter6.95 of BOILER-COMP(OVER 100,000 BTU)
theerstandtatifthbuildiycode, et Sections
ctly have
a tenant,
that It
APR 1 199i
,ueCalif California
Health building ode not correctlyyhave 33andt,thrt It Ls my NEW RESIDENTIAL METH. �.FT
responsibility to nosily the comport of the requirements which must be met as
/.
prkr,to Issuance of a Certificate of Occupa my. CITY Ut- IaUF'Cnin4
Owner or authorized agent Date �� ISSUED BY•
OFFICE COPY