23990 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Buildingproject identlllotlon - .PERMITNO.
Budding Address: /�3^ n O
�., Z G Vy
woes hone.
CITY OF CUPERTINO-BUILDINGDIVISION
APPLICATION / PERMIT LV�`
- + BUILDING-ELECTRICALPLUMBINC•M[CHAMCAL CATEGORY CONTROLp
Architect/Engineer, Lk.No:
QTY i' ELECTR1 . IC PERMIT FEE BUILDING PERMIT INFO,
Address: - PERM TISSUANCE �� ❑ ❑ ' ❑
LICENSED CONTRunder SDECLARATION
Iherehy affirmthat lam licensed underprovhlonPro Chapter9(e,.ndm APPLIANCES JOB DFSCIiRTION
Ingwlth 1 Uon force
effeon3o(1he Butlr�cuandPmleuloneCode,and my
limner i•ie full form and e. PANELS '
License Class LIc.N /'�^ . a A•r
Date Cootradoi "I•�i'<De Y71/,'jtfrl
ARCHITECTS DECLARATION 201-1000A.MPS
re0 O I understand my plane shall be used as public records.. OVER l ODD AMPS SQ.FT:FLOOR AREA $/S .Fl.
6i Limned Professional SIGNS ELECTRICAL pop
�<<6 OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC ^ 0 L�
owingUnneason.(batlamexempHro ossa Contractor's License AnyLaw for he
polollowingreuon.(Sadion7031.5,BuslnemandPro(essionsCode:An dl or 1(n1
OZF•pp - Y Y TEMP.METLR OR POLE INSf. is
a,: i J '
p;� ty counlywhichpdortorequiress permitlomnrequid theaprovgdemoBeh,orrepao 11 II
as an .signed
rsomme its W,he I,liceealso sed pursuant 1 the provisions
of he POWER DEVICES /tiJ
O file a actor's &dement that ha Is r9(coed pursuant it the provision of the / -
u, Contractors License Low(CMpler9(mmmencing wlthSection 7000)o(Divi.
�0 slon3ofl1e Butl euandrrofe r Code)orthathe IseaempIlhercfromand SWBdhENC POOL ELRCIRIC 91
TION
A the bash for the alleged exemption. Any violation a(Section 7031.5 by any OIITLEISSWITCHESFIKTURES -�
applicant for a permit subjects the applicant to a civil penalty of not more than
fq� five hundred dollen(8500).
I,as owner of the property, - NEW RESIDENTIAL ELECTR SQFT. - STORIES - TYPE CONSTRUCTION
�n ❑ p perry,or my employers with wage as offered
dole
C rom(Sec.ti on,70K wilidothe Business and Professions
Coc[urche is ot Contended orrcense Lw
E sale(Sec. pply toalnan owandf property
Code:The Compactors License Law
$ does not eppl.,khiwnero(pmpenywhobuiWsayimproves dhdth theme,and " OCC.GROUP RES.UNITS
who don such work himself orlhrwgh hie awn employers,provided that aucF
Improvements an not Intended oroffered torsale.If,however,thebulldingor
improvementisaoldwithlnoneyeaio(coropldlon,theowner-Wilderwillhave
the burden of proving that he did not build or improve for purpose cleats.). QTY, PLUMBINGPERMIT FEE FLOOD 21DNE APN
LJ I,as owner of the property,am eaiu•Ively=trading with limned PERMITISSUANCE '
mntradon to contract the pmjed(Sec.7614,Business and Professions Code:
The Contndor.License Law does not apply to an owner of property who ALTER-DRAIN kVENT-WATER(EA)
Wilds or Improves thereon, and who mntrada for such ptojeda with
gfLt(actort)Iicenv:d Ponumet to the Contractors License Law. FEE SUMMARY
Ldl amsexempt under Sa. B k P C for this rcawn BACK FLAW PROTECT.DEVICE
OUTSIDE FEES
Owner. Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_RECEUT N�
WORKMAN COMPLNSATION DECLARATION p0('IVRBS PER TRAP SCHOOLTAX Y N
of hereby affirm that I have•certificate of commentaudifi d pythemo ora RECEIPT N
moo'uniflabc.Workers'Compenatlanlrtsuran¢oramrUficd ropy lhemol($ec. GAS EA SYSTEMI INC401TTLM PARK=- Y N
3EOQ Lab C.)
Policy N - RECEE'T M
Com an - GAS F.A.SYSTEM.OVER 4(EA)
❑CY - 'BUILDING DI VIS ION k'EES
l(Ied copy is hereby furnished, CREASE/INDUSTRLWASM INTERCEPTOR PLANCHECK FEE
❑CcAertified mpybfiled with the sty inspection division. '
CERTIFICATE.OFIXEMITION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Recei t#
(pNssedbn nand rad be ENSATI Nthepermat SURA Isfworw hundred dollen
(5100)or leu.) - WATERHEATERW/VENT/I9.CCTR ENERGY PEE Y N
I mililythat in the peck rmanceof the work(orwhleh this permit is Issued, —
1 shall not empley any person In any manner so u to become subjed to the WATl72 SYSTEM/TRPA77N'G
W.dmo%Compensation Lawn o(CaIif.La.Data _ PAID
0 Z Applicant
ZO NOTICE 10 APPLICANT.If,after making this Cartlflate of Exemption,you NEW RESIDENTIAL P[MB. SQ.FL , Date Rotel t#
Hshould become sobjed to the Workers'Compenation provlsloru ofthe Labor TOTAL:
W
Code,you=at forthwith mmpcy with such provisions or this permit shall be
W 9 deemed revoked. - .BU1 IN FEE
0. CONSTRUCTION LENDING AGENCY SEISMIC FEE
M G Z IherebyafRrm that there b a contrudion lending agency for the perforrtr ELECTRIC FEE
ante ofthe work for which this permit is Based(Sm.3097,Cly.C.) TOTAL:
U Q lender.Name PLUMBING FEE
IL F LendeisAddress QTY. MECHANICAL,PERMIT FEE" MECHANICALFEE
Icertilythatl baveread this appllaHmerul statethal theabwecnformatlon
.0 W
6 Ismrred.l agedto comply with all city and county ordinances and date laws PERMIT ISSUANCE FEES PAID:'
} N relating to building construction,and hereby autgorize representative•o(thls
(•.. Z sty to enter upon the abovementioned property for lnpectlon purposes. ALTER OR ADD TO MEGH. Date ReCei t#
_ (We)agree to save,Indemnify an d keep harmless the City of Cupertino P
aga1nt11abi11Hea,Jadgmenb,meta and expe��ycome AIR[iANDWNG I1MT p010,000CFM) SUBTOTAL:
Id City in col xenceo hegrasAIR HANDLING UNIT(OVER I QOOOCFM) CONSTRUCTION TAX
Signature of Appllant/Contractor EXHAUST I IOOD(W/DLIC'D CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE -
Willtheapplicantorfinure building occupant store or handle bavrdous HEATING UNIT(TO 100,000 BTLJ)
material as defined by the Cupertino Municipal Code,Chapter9.IZ and the _ Date Recel I#
(Iealth and Safely Codc Sod1on 25532(.)2 HEATING UNIT(OVER 100,00)am -T
❑Yes rL.��No
Will the applicant or fu numbucldingmccupaNuseequipmenl ordeAces VENHILATIONFAN(SINGLERESID) - ISSUANCE DATE
which emit barardous air contaminants as defined by the Bay Area Air _
. Quality Management Distrld7 I BOR.ERCOMP OFB'OR 106,000 BTI!)
4 Yrs 9 No
hour read the hares ous materials requirements under Chapterb.95 of BOILER-COMP(OVER 100,000 BTU)
the Cailfomb Health k SafiCode,Sedlon 25565,25533and 23534.1 - p
understand that lithe building does not eurrently have a tenant,that It is my NEW RESIDENTIAL MECH, SQ.FT. ~ f
responsibility to notify the occupant of the requirements which must be rtaM
pd-rtocssuance o(a CertificateofOmupancy. - JUL 0
Owner or authorlred agent Data - ISSU�F.��Y{ e
TOTAL: CIFD
i
OFFICE COPY