23076 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERhLH NO.
Building Addrcsa:I 0'663 23076
e r—Fvt
one: A A A
CITY OPPLICTTNION / PEEO�BUILDING DIVISION t^ —L _cu
uoNo: APPLICATION I PERMIT L O
.tAOO S(, O BUILDINGELECTRICALMU BING- CATEGORY CONTROL#
' Arch¢ed/Engineer. Lic.No: MECHAMCAL
qTY ELECTRICPERMTT FEE BUILDING PERMIT INFO
Address:
PERMITISSUANCE 1:1 El ❑
LICENSEDCONTRACTORS DECLARATION
I hereby affirmthat Iam licensed under provisions o(Chapter ode,anme- APPLIANCESRESIDENTIAL JOB DESCRIPTION
ingwith full 7000)of d offeon3ofthc Busimsaand Pm(aaionsCode,and my
limns lain full( and c. / IO� PANELS
Lirnnx ContUP TO 200ALVSractor Date Contractor e
ARCHITECTS DECLARATION 201-1000A.MPS
aO ZpC I understand my plans shallbe used as publicrecords. OVERI(UBAMPS Se.[XR7Eq a s/Sq.Fr.
U Licensed Professional SIGNS ELECTRICAL C u N
m OWNER-BUILDER DECLARATION P U T E R
�n Ire SPECIALCIRCUIT/MI5C
1' a Ihercbyaffirmthatlamexemptfromthe Contradorb Lirnnx Lawfarthe
following reason.(Section 7M S,Business and Profession Code:Any dry or
9 ,
O G F-u9 TEMP.METER OR POLE INST.
FSg� muntywhichmquimaper ttommtmd,alter,impmv demolbh,ormpair T
ofe ,,JG anystructure priorto its Issuance,alsorequires Neappllcant forsuch Fermat to POWER DEVICES
O 0 O file a signed statement that M b licensed pursuant to the provisions of the
O
Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi-
3p�+ usiness SWIMMING POOL ELECTRIC
'he olthe theallegedProfessions Any
rlationthat f exempt therefrom and VALUATION��
the bash for the alleged exemption. Any violation of nattySection not
by any OUTLEISSWITCHFSF(XTURES CCiiI�?
"O applicant fora permit subjectsthe applicant toa dull pemltyofnat nnrethan
five hundred dollars%SM. NEW RESIDENTIAL ELECT#
Z¢
F-1 1,as owner of the property,or my employees with wages as their sole SQJT. STOW FS TYPE CONSTRUCTION
compensation,will do the work and the structure b not Intended or offered for
O sale(Sec 7014,Busbies,and Professiors Code:The Contractors License law
doesnotapply to an owner of propertywho Wilds or improves thereon,and
who docasuchworkhlmselforthrough hbown employees,provided thatsuch OCC.GROIIP RES.UNITS
improvements are not Intended oroffered forage.If,however thebuilding or TOTAL:
Improvement ismld within oneyearofrompletion,the owner-W ilderwill have
th rdenofprovmg that he did not Wlidorimproveforpurprseofsale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
Lj L as owner of the property,am exclusively=trading with licensed pF12MRIS5UANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
the Contructors License law does not apply to an owner of property who pL'IFR-DRAIN&VENT-WATER(EA)
Wild. or improves thereon, and who contracts for such p4oject,with a
mp(pdorts)limned pursuanelothe Contractor'a LlmoseLaw. FEE SUMMARY
Bq�}TpW PROTECT.DEVICE
LII am exempt under Sec. 0 k P C for this ..on
• Owner Date DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RECEIPT#
❑1 hereby affirm that I have a certificate of consent to self-Insure,or a FIX'NRF_S-PER TRA SCHOOL TAX Y N_
mdifimteof Workers CompereatfonlmumnmaramAlfhdcopytherea((See. RECEIPT#
Mail,Lab C.) GAS RA.SYSTEM-1 INCAOUITLEIS PARK FCE Y N_
Policy
RIN��
.y GAEA.SYSTEM-0VRR4 LEA) BUIL
S '
VI FEES
❑pCertified copy is
hereyfs eabyturh thenishecl.
city
GREASE/INDUSTRL WASTE INTERCEPTOR PLANCI'JECK FEE
❑Certified copy inspection division.
CERTIFlG MPE SATION N FROM WORKERS' GAFi35E TRAP
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT ate Reeel t#
QMssedlon need fid be completed If the permit tilorone hundred dollars
(410 redifynJ WATER HEATER W/VENT/ELECTR RG FE N
1llnot thatinthe person In
for which this permit is booed,
1 shall rs' employ any Person In any manner so u to become mbjed to the WATIR SYS EM/TREATING
Workea'Compensation laws o(CaBfomla.Date PA D
O Z Applicant NEW RESIDENTIAL PLMB. SQFT. ate Recei t#
Z Q NOTICEco MPLICt to
after makinrs'Co thisCertificate
Pro o(Exemption,eLabor
you
should
oumus nu forthwith
co Workers'Comprovidmorthlomrmit of s Lab he TOTAL: _
LU N Cods,youcomply with such prowions or this perMtshallbe
> deemed revokes. BU MNG •-E
LU
G CONSTRUCTION LENDING AGENCY SEISMIC FEE L
I hereby afBrmthat there b a construction lending agency for the perform ELECTRIC Er Z anm of the work for which this Fermat b Issued(Sec.3097,Civ.C.) TOTAL:
Q O lenders Name PLUMBING FEE
14, !— lenders Aaareaa QTY. MECHANICAL PERMIT FEE MECHANICAL •E
O W lmrtalythat l haveread this appliedionand statethat theabove information
a Is correct.l agree to comply with all my and county ordinances and date laws PERMIT ISSUANCE FEES PAID:
} relating to building construction,and herebyauthaden representatives of this
F city to enter upon the above-menuonsd property for inspection purposes. ALTER OR ADDTO MECH.
U) —
— (We)agree to save,indemnify an d keep harmless the City of Cupertino Date eeeiptH
against liabilities,judgments,coats and expenses which may In anywayamme AIR HANDLING UNIT GO Ill"CFM) $U TOTAL:
against said Cit M oscpre oft gof this permit AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION AX
SI tum oaAppOont/ ontrador —Da2 EXHAUST HOOD(W/DIKT) CONSTRUCTION AX PND:
HAZARDOUS MATERIALS DISCLOSURE
all the pplicant or future building occupant store or handle hazardous HEATING UNIT(TO H0,"BN) Date CCeI tk
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I Ir.1th and Safety Code Section 25532(.)7 HEATING UNIT(OVER He,"BTI) TAL
❑Yesn No
Will the applicant orfuture building occupant use equipment ordevices VFNIILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havardoua air rontaMmnts as defined by the Bay Area Air
®
Quality Management theent Disladl BOR.RR-COMP OHP
OVER 10OgIXq BTU) — 1�
qY, �No nn pp
have ria tcahaza fmy Codc,Se rcors 255 nts 5,2553 and apter 255341.1 o! BOILHR-COMP(OV[R 11p,000BN) P p4,
the Calilo ulicalth ASafety Code,Sections 25505,7x537 and 25534.7 (�
understand that lithe building does not currently have a tenant,that it is my NEW RESIDENTIAL MF.CH. SQ'�' DEC lg
responsibility to notify the occupant of the requirements which must be root 1991
priormisuance ofaCerti Ocatcof Ocmpancy. 9 9 -
Owner or authoriced agent Date CI I r V Ink rgVk r _
TOTAL: ISSUED I
OFFICE COPY