23435 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
ui : BuildingProject Identification PF]thu7N0. '4 3 5 a
BuildingAddress:
S �rz� S �,
wne . cess .�� ane:
AS --2,' y - CITY OF CUPERTINO-BUILDING DIVISIONZ—
Contrador's Lk.Nm APPLICATION /PERMIT [(
c' Architect/EnglnnV Lk.No: RUILDINGELECTRICALFLUMBINO-MECHANICAL CATEGORY' CONTROLM
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE ❑ F-1 11PLUMB Ml�lf
LICENSED CONTRACTOR'S DECLARATION
I hereby afftrn that l am licensed under provWonsofChapter9 immature. APPUANCESRESIDENTIAL 705 DFSCRITION
Ingwith Se on7000)of Dlvielon3ofthe Busies and ProfguonaCode,and my
license le In full force and effect PANELS S
ense Clava Lk.M
D 1( AV\
Date Contractor � VV✓✓
ARCHITECTS DECLARATION 211-IOW AMPS
asz I understand my plsm shall be used as public records OVER1000AMPS SQ.FT.FLOOR AREA $/SQ.Fr.
00
(y () Licensed Prof andarad SIGNS EL L '
OWNER-BUILDER DECLARATION g1•BCIAL UI
Ihercbyafftrtn thatlam exempt lromthe Contractor's License law(mthe
O t. following recon.(Section 70315,Business and Professions Code:Any city or TAMP.M L I
�� cauntywhkhrequlrnaper ttommtrud,alter,Impmve,dem lbh.orrepalr
gg''x6 anyatracturn priortolbbsuance,also requlreslhe applicantforsuch perdtto POWER DEVICES
e{ (5 file a signed statement that he In licensed pursuant to the provisions of the
3w� Contractor'aLice.Lw(Chapter 9(mmmenclng with Section 7000)of Divi- SWIMMINGO sion3ofthe5ew ugnand Pefenloro Cod0mthG he lsexempt therefromand FIRI 9 P
- VALUATION
O the basis for the alleged exemption. Any violation of Section 70315 by any OUILEISSNTTCHFSFTK'IURES .J O
applicant fora permit subjects the applicant to a civil penalty of not more than J
ve dred dollars($50e). SQ.Fr. - TYPECONSTRUCTION
0a asowner ll the property,orhe employees Inwithwages r their sole NEW RESIDENTIAL ELECTR FI.
pece.70 ,Buldotheworkandthestmdurebnot Intended oroffered for
q e(Sce.apply
to alma and f property Code:The Contractor's Licenseherein law
�Q don not apply torn owner ofpropertywho nempoyees,povided roes,and OCC.GR0UP RES UNITS
��C��CLLLLLL
who
pmvcrnsuch work Mmself or dedorafferedhis owne.If,hoevertlebuildithat auch
improvements wid lntenowyear fcompletokthown veg deer ldingoe TOTAL:
Improvementlswldwithln oneyearofcampletlon,lheowner-bullderwlllhave
t"rdenof pmvingthat he did not build orlmpreve for purposeol We.). QTY, PLUMBING PERMIT FEE FLOOD ZONE AI'N
LJ I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contndors to mmwd the projM(Sec 7014,Businean and I'mfeasiav Code:
The Contndor's License law don not apply to an owner of property who ALTER-DRAIN&VENT-WATER ffA)
builds or Improves thereon,and who contracts for such p4ajects with a FEE SUMMARY
ctorcease(s 5ceapursuanttothe Contractor's LicenseLaw. BACKFLOW PROTECT.DEVICE LJ I am Sec. B&P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
.Owner - e RECEIPT#
OMPENSATION DECLARATION FDaURF&PER TRAP SCHOOL TAX Y N
❑I hereby rm that I have•certificate of consent to alFmwre ora RptOpT.»
certificate orkens Compernaion lrouranceora certl(kd copy thereof0rec. GASYSrFM-1 C.40IJILEl5 PARK FEE N_
3500,4b Cd S E.A. WY RECEn7#
Policy
C[] CAS EA.SYSTEM-OVER 4(EA)
am BUILDING DIVISION FEES
CertBled copy hereby CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
QCcrti(led mpyb filed with the city city inspection division. '
CERTIFICATE OF EX IM. PTION FROM WORKERS' GREASE TRA' PAID
COMPENSATION INSURANCE SEWER-SAMTAtY STORM EA XpFT Date Recei t#
(Thosetion need not be completed tithe permit ls farone hundred dollars
(a1 W)arleee.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y _ N
Icertitythat Nthe pertonnanao(the wok forwMrh this pemdt is lswed,
I shall not employ any person In any manner n as to become subject to the WATER SYSITM/TREAnNG
Workers'Campcm,s6.n Lawsof CalRomla.Date PAID
Q Z Applicant NEW RESIDENTIAL PLMB, SQ.Fr. Date Revel t#
Z O NOTICETO APPLICANT:If,after making this Certificate of Exemption,you
Hshould become subject to the Workers'Compensation Frontal oro o(the Labor TOTA
N Code,you moat forthwith comply with such provisions orthia permit shall be UI IN ( t��
W � deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
Il a Ihereby afftrmthat themb a construction lendlegagency for the perform- ELECTRIC FEE
O ance oflhe work for which this permit b bound(See.3097,Civ.C.) TOTAL:
Lenders Name PLUMBING FEE
LL F Lenders Addren QTY. MECHANICAL PERMIT FEE MECHANICALFEE
O W Imnitythatl have read lhbapplkatonand state thatthe above Information
R is correct.l agreclo comply with all cityand county ordinances and Gate laws PERMITISSUANCE FEES PAID:
relating to building construction,and hereby authorlu representatives ofthis '•
F N city to enter upon the abovcmentloned property for inspection purposes. ALTERORADDTOMECH.
? (We)agree to save,indemnify an d keep harden the City of Cu pert Ino Date Revel t#
V a'.out d rata,centsand expenses which may In anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against inmequenceoftheacting ofthis permit.
• �--�ffi_ AR HANDLING UNIT(OVER IO,000CFM) CONSTRUCTION TAX
Ir.nare enmranor Date EKHAUSTHOOD(W/DUCn CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
W
illfiant or forms building occupant store or handle havrdous HEATING UNIT(TO 100,000 BTU) Date RCYeI l
rened bythe Cupertino Municipal Code,Chapter 9.1$and the
Mty Code Section 2553TU)7 IiGTWG UNIT(OVER 100,000 BTU) TOTA
• M No
Will the applicant orfutumbullding occupant useequlpmrm or devices VENTILATION FAN(SINGLE RFMD) ISSUAN'FPATE
which ealitmit hamrdous air contaminants as defined by the Bay Area Air P /per
Quy Maiugemenl Dlsldct7 BOILER-COMP QHPOR 1 00,000BTU)
Yesn❑No
hove read the hse,[ ous materials requlrerrenb under Chapter 6.95 of BOILER-COMP(OVER IW,OW BTU)
tj the California Health&Safety Code,Sections 25505,25ST3and 25534.I MAR 23 1992
understand that if the bullding don not currently have a tenant,that it my NEW RESIDENTIAL MECH. SQ.FT
responsibility to notify the occupant of the requirements which=at be met
prlmtoissuanmoraCcAlfiateofO=pancy. f.^III UI- CUptnI II iV _
Owner or authorised agent Date
TOTAL: ISSUED BY: 6
OFFICE COPY