23135 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Fell Identification
Building Add... PERMITNO.
,nvner� oLAID4 Vi23135
s% one
6qJ�gaQadCITY OF CUPERTINO-BUILDING DIVISION
VT Ac`/1 JL APPLICATION I PERMIT
I
Architect I g1 tic N BUILOINGELECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address,
7 — kI �mt` M�
PERMITISSUANCE 1:1 1:1 ❑ K[
I hereby LICENSED CONTRACTOR'S DECLARATION affirm that l am licensed under provWonaofChapter9(mmman APPLIANCESREEDENTIAL
ingwilh Settkn7000)of Dlvislon3afthe Budnessand Profes deralCode,and my JOB DESCRIPTION
license Is In full r Ypd efrecT. PANELS
Lite Is Lk.Y S J S.g -
Date Contactor
ARCHITECTS DECLARATION 701-1 000 AMPS
. OO Iunderstand my plans shall be used es public records OVER 1000 AMP$
SQ.FT.FLOOR AREA $/SQ.FT.
Licensed ProlesslorO SIGNS ELECTRICAL fL s... ® O
< OWNER-BUILDER DECLARATION 4/�1 6E
Q I herebya(firmtFul l—exempt from the Contractor's Lfceme Is.forthe SPECIAL CR2CUIT"U`C. All
70 Z follow
reason.(Seetlan 70I1.5,Buslnen and Pro(essbns Code:Any city or
�� rountywhich rcquiresa permit tomnstmcl,alter,lmprove,demoWh,orrepair TFMP.METER ORPOLE INST. Ve fU�U(
any atmcturc prior to ltandtarice,alaorequbntheappBantfineuch permit to
(� fila a dgned datement that he h licensed pursuant to the proehlons of thed!%q
3 O ContrattoYa License law(Chapter9(commencing with Section 7000)of Dlvl- �[
dun3 ofthe Elude good Professb-Coda)or that he h exempt thercfromandLECTRIC A O
yfb S rhe bash for'he
alleged exemption. Any v(olatIn o!Sectkn 7031.5 by any aPPllant(ora permit aubj.Re the pp
toativll para ltyof not nnretlunFI%TUftF9hundreddolhn(51DI,as owner of the pormymptoy
h wage as their axleELECTIt__SQFI. STORIES T1TE CONSTRIX:TION
c mpemaHon,willdo Me work•end thedatture hna ktended ur of(am (or
O sale(Scc.7069,Buelnesa and Pro(essloro Cade:The Contact.".License Law
'$ does not apply to an owner afproperty who WlIdeorimprovnthereon sod
whodoessuchworkhimsel(orthrough hieownemploym,provWed that such __755C GROUP RFS
.UMTS
Improvementaare notlntendad orofferad fatale.If,howeveL bunclogor TOTAL:
improvementhsold withlnoneyearo(complellon,theowner-bullderwW bave -•
1fLjLanof wner of the t he poertret bund or Improve for purpose afaak.). QTy, PLUMBING PERMIT FEE
uu 4 an owner o!the property,am exclusively contncting with Ilreneed FLOOD TONE APN
contactors to construct the projm(Sec.7096,Businessland Prefeaslorude:
CoPERMIT ISSUANCE
The Comaaore Limnae Law does not apply to an owner of property who
Wilds or improves thereon,and who commu4 for such projects with a ALTER-DRAIN&VENT-WATER(EM
�q➢I[actar(s)lk nwd pursuant to the Contndm'a Llmnsa Lew. FEE SUMMARY
Lj I am exempt under Sec. B &P C for this reason BACK PLOW PROTECT.DEVICE OUTSIDE FEES
. Owner Date DRAINS FLOOR ROOF,AREA,COND, SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION BBC=a
hereby affirm that I have a certlfiate of cal to self-Insure,a• FIXTURES.PER TRAP SCIiOOL TAX Y N
ccft13800,lcate of Workere Compensatim Luurana oraanifled mpythemof(Sec. RECEIPT Y
3800,Lab �F GAS EA.SYSTEM.1 INC.6 OUTLETS PARK FEE Y_ N
CPooIT Y YCQ),2Q JT J�'O) RFEEB°Ta
Y dtane, CAS FA SYSTEMOVER6(EA) BUILIIINGDIVISIONF'EES
Certified copyh a (umlehed.
�CertlOed copy ex filed with the city inspection division. GREASE/GIDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
Rhlssectlon need rat lncomplated i(theperMt after one hundeaddollars SEINER-SANITARY-SIDRMEA.2OD7. Date Recei (#
($100)or Iess3
Illnot thatln any p.
fell this permit is Issued, WATER HEATER W/VENT/FLLCTR ENERGYFEE Y N'
1 shall not employ any person In any manner an as to become subject to the
O Workers'Compensatlen Laws of California.Data
WATER
PAID
Applicant
Z 0 NOTICETO APPLICANT:ILaflermakingthh Cenifateof Exemption,youSQ3.T; Datewldbemeub}cttothe Workers'Compensation proviiore of the LaborTOTAL:
Code,you must(orthwlth comply with such provisions or this parrt shall hedeemed revoked. B DING FEE
CONSTRUCTION LENDING AGENCYSEISMI herebyaffirenthat there h a construction lendingagency forthe performELECZ ana of the workfor which this permit h haued(Sec.3097,Civ.C.) TOTAL:O Lender'sName PLUMBING FEE
LL H Lender'sAddmse IT FEE
O W 1cal hatl have read thhappilatlon and datethatlheaboveinfarmatlon MECHANICAL FEE 0
IL Is corenct.I agree tocamply with all dtyand county ordinances and data laws ( PERMIT NUANCE FE PAID:
W relating to building constroodon,and hereby authorlae representatives ofthh
Z city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH.
V — (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Rectl
against llablWla E�ente,mdaandex enanwhlch nay In any wayamue AIR HANDLING UNIT TO 10,000 CFM) SUBTOTAL:
against sal nsequence o(the ,sating /this permit.
AIRHANDLINC UNIT(OVER 10,030CFM) CONSTRUCTION TAX
Sigwtureol AppB nOaaer -RDOUS MATERIALS UISCLOSE Date EXHAUST HOOD(W/DUCT CONSTRUCTION TAX PAID:
Will the applicant or future Wilding occupant store or handle harsrdous HEATING UNIT(TO 100,030 BTU)
materia l as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the Date Reuel IN
Health and Safety Cade Section 25532(a)I HEATING UNIT(OVER 100,000 BTU)
❑Yea N No 'r DQ TOTAL: .m b
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) 1$SUAN6E DATE
which emit hazardousair com neranteas defined by the Bay Area Air QY P+ 1 v Quality Management Dlsldct7 BORER-COMPOHP OR 10000 BTU)
qYea I�Na
have read Ir.Ithe rets Code,terils Scole.rerrenb5533 and 255346.95 of BORER-COMP(OVER 100,000 BTU) BEC26 1991
the Californiatand Health building
Code, otcurentlyh have
at and75539.I
understand that n he notify
the occupant
not the
encs which
thatit
not FLEW RESIDENTIAL MECH. SQ.FT
responsibility to nal(y the oavpant of the requlmmenls which mus[be ma
prior to issuance of a Certificate of Oaupa nay. CII I Uh CU"CM I IIVV
Owner or a.thmiecd agent Date
TOTAL: _110 ISSUEDBY:_
OFFICE COPY