21027 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES _ USE BALL POINT PEN ONLY
Bulldin Via'edldemificatioa PERMIT NO.
Building
Ilia a& LINDA V'ITrA ngIVE 21
027
nets"Ea�
APPLICATION SUBM177==__
S M, NI SSS M �'S`'7 572 CITY OF CUPERTIN0.BUILDING DIVISION �'r rO�
e LIc.No: APPLICATION I PERMIT 1l l Xt r a p e v t c I. Lf B 7 D• BUILDING ELECTRICAI PLUMBING-MECHANICAL CATEGORYCONTROL X
er. - Lic.No: QTY ELECTRICTERMIT FEE BUILDING PERMIT INFO
PERMITISSUgNCE ❑ ❑ENSED CONTRACTOR'S DECLARATIONthatlam Bcmeed underprovWon-of CEapter9(commen APPLIANCESRESIDEN'MLJOg DESCRBR[ON
ngwtWon7000)of Div sion3ofthe BusineaandPmfesslonaCode,md my
limens Is In fug force and died. PANELS
License Clam .
Datemdr N
' CContractor
ARCHITECTS DECLARATION 701-1000 AMPS -
00 1 ed..t.W plan shall be used public records. OVER1000AMP5
r^YP pia SQ.FT.FLOOR AREAS/SQ.IT.
ly Licensed Pmfessloal SIGNSELECTRIGL
-4 1OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/zF• 4 I herebyafflrrnthatlamemoapt from the Contractor's License 4wforthe
O ZO following reason.(Section 7031.5,Business and Professions Code:Any city orI
county which require-a permit to mrehuct,alter,Improve,demolish,or repair '>F•M METFRORPOL
any at statement
he Jai alwrequ pursuant t the provision
of to ]O EVICES
BIB a signed statement that he b licensed pursuant to the pro 7000) of the
n, Contractor's License Lew(Chapter9(commencing e6 exempt
herefof and SWIM GIY10
Ori elon3o(the Buelneasand Profession Code)ortha[hebexempttherefromand / �UVALUATION
the basis for the alleged exemption. Any etiolation of Se tion 7031.5 by any OUTLE WI �(((SSSJJJ/_ '
O
applicant for a permit subjectsthe applicant to a civil penalty of not morethan
$ five hundred dollars(ISDO). r'
�n
F11,a owner of the property,or my employees with wages as their sale NEWS D AL ELECTR .Fr 51URIP5 TYPE CONSTRUCTION
.4compensetion,wgldothe work,andthestructureb not Intended or offered for
O sale(Sec.7044,Business and Professions Code:The Contractor's License Lew
$ does net apply to an owner of property who build-or Improves thereon,and '
who doessuch work himself orthrough his ownemployees,provided that ouch OCC.GROUP RPS.UNITS
Improvements are not intended muttered forsale.If,however,thebulldingor TOTAL:
Improvementiesold withinomyearofcompletiorythe owner-bugderwlll have
t1rden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE pLOODZONE TP
I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE'
contractors to construct the project(Sec.7016,Business and Professions Cade: '
The Contractoes License Law does net apply to an owner of property who
Wilds or improves thereon,and who mmrats for such ptojetts with a ALTER-DRAM&VENT.WATER(EM - -
cgRt{ator(s)licensed Pursuant to the Contractor's License Law. FEE SUMMARY
LJ I am exempt under Sec. B&P C for this recon BACK FLOW PROTECT.DEVICE
CUTS' FEES
Owner DRAINS-FLOOR ROOF,AREA,COND. SANITARY Y N
Date RECEIPT X -
WORKMANCOM EWSATIONDECLA A ION
[]I ereby affirmWorkers
that I have a mrtranx,r of consent to copy
thereof
ora I+D('IVRFS PER TRAP SCI100L TAX Y N
3800,La a of Warken'Compeaatlonlnsurmce or a mrtifledcopy thereof(Sec. AECEB'T X
3500,4b 173 GAS EA.SYSTEM-1 MCA OUTLETS PARK FFR Y - hl
Policy M RECEIPT It
Com any GAS EA.SYSTEM-OVER4(EA)
Certified copy is hereby furnished. BUILDING DIVISION FEES
[_]Certified copy is Ned with the city Inspection division. GREASE/MDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE
(Thissedion need netbe completed if the permitSEWER-SANITARYis fmone hundred dollars STORM EA.2001+17. Date Recei t#
(5100)orlessJ WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certify thatInthe person
of the workmnner for witch this penultcbooed, —
I Whale not employ an/person In any manner so a to become subject to the
WormpensaHon Leas of California. ATQt SYSTEM/,TREATING
la.Date PAID - -
O Z Applicantlicant
Z O NOTICE TOMPLICt to
orkem'ldngthb ation pro is Exemption,you NEW RESIDENTIAL ELMS.' SQ}T. Date Recei t#
H shoed become forth it the Workeit Cuch pnmtlonprovbis permit s Labor - TOTAL:
WW dede,you medra=at forthwith comply with such provbba or this permit shall be
> deemed revoked. - - BUILDING FEE t co
(L c CONSTRUCTION LENDING AGENCY SEISMIC FEE L
I hereby affirm that there is;a construction lending agency for the petornF
Oance of the work for which this permit b issued(Sec.3097,Civ.Q TOTAL: ELECTRIC FEE
V _ Leader's Name PLUMBING FEE
LL F Lender.Addresa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Iredifythatlhavereadthisapplimtlonandrtatethattheaboveinfornation
Is correct.l agree to comply with all city and county ordinances and data laws PERMITISSUANCE FEES PAID:
N relating to building construction,and hereby authorize representatives of this
Z tt(Wa) erupon the above-mientioned property for Inspection purposes. ALTERORADDTOMECH.
(We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
L) against lWbigtles,judgo:ante,crunand expenses which may in anywayaccrue AIR HANDLING UNIT(To to,000 CAM) - - SUBTOTAL:
garb i staid City In consequence
of the granting of this permit.
�C II.•��wsfi+. '7"'I �'/Lt1�a, 9�13/90 AIR HANDLING UNIT(OVM IO,ODOCFM) CONSTRUCTION TAX
gnat of Applicant/Contractor Date ExHALTsTHOOD(W/DUCD CONSTRUCTION TAX PAID:
(/ HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfutum building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Cad tion 25532(.)7 ' HEATING UNIT(OVER 100,000 BTU) TOTAL; C•
0 Yes p�$No
Willtheapplimnt Rr Nture building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) AN�E DATE ISSU
which emit hawrdou-air contaminants as defined by the Bay Area Air IS BBQ
Quality Maagsmen tit? BOILER-COMP OHP OR 100,000 BTU) ILL�i
❑ Ye- No
Ihave read thehaza ous materlab requirements under Chapter 6.95 of BOILGR-COMP(OVER 100,000 BTU) y
the GlBfmla Health&Safety Code,Section 25505,75533 and 25534.I CV 1 ( c7
understand that if the building does not currently have a tenant,that It b my NEW RESIDENTIAL MECH. E
mSQFr.
respuibilityto a"By the occupant of the requirements which must be met �s�p� as� .{.as'f�
prior to Issuance of a Certificate of Occupancy. �IJaZ TIL An�pI.N1SLE
nerorauthorizedagent Date ISSUED BY: � • I�'— '
TOTAL:
OFFICE COPY
' I