24190 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building ero<T Identification mrE1tFBT N2 419 0
Building Adda:
040/ �/NpSAY Af/6.
rte , are: ane:
DA✓rS ,Z S 2—OR CITY OF CUPERTINO-BUILDING DIVISION
Contract.e.Name: Gc.Na: APPLICATION I PERMIT
t .L/ON h^4,e-r /OCT vlfei•t96 620$Q,Z, CATEGORY CONTROL N.
rchit./Engineer• - BUILDINGdFL'IRICALPLUMBINGMECHAMCAL
Lk Na
QIY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addreac ❑ ❑ ❑
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Thereby affirm ltatlam licensed under provisions
felona of Chapter9(commen APPUANCESRESIDENTIAL JOBD N
Ingwlth Seedon7000)of Dlvsion3ofthe ButlnenandProfesaionsCo and my
license Is In tui end effect. PANELS n F.Lirena Clan o b LION 6.Zo 39z 1(/r" F
Date Contractor ro�4 7�.
—UP TO 200AHM
ARCHITECTS DECLARATION 201-1000 AMPS
W� (understand ren plan shagbu used upublicrecoMs. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
V Licensed Profenlonal SIGNS ELECTRICAL
/a OWNER-BUILDER DECLARATION SPF-CIpL CIRCUIT/MLSC
>F � IherebleaffirmHm
ullaexereptfromthe Conn
tctor'sLlcenseLaw fee the
OgH— fa0owing reason.(Section 70115,Businea and Prolenbns Code:Any city or
csuTEMP METER OR POLE INST.
P5 nlywhlchrcqulmaper tomratvci,alter,Improve,de=1(3h,ormpalr
y nystm mpriortols Wuame,asorequlrestheappUmntforsuchpermitto POWER DEVICES
a file a signed statement that he Is licensed pursuant to the provinces of the
3wy Coniradorb Llcevelaw(Cl pter9(mmmencingwRhSeR1on70fA)ofMvl-
�O"J elon3 ofthe Business and Pro(enlov Cade)orthm he beampt therefecmand SWIMMING POOL ELECTRIC VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant for a permit subjects the applicant to a civil penalty of na more than OUTLETS.SWITCHESF'IXTTIRES
N
five hundred dollenhe Pro NEWRESIDENTIALELECTR SQFL
❑I,as ower of the property,at myt employees n with ended ss their sole STORIES TYPE CONSIRIX:TION'
compec.70 ,Business
rodmihescode: le not Wended License
ed for
Law
O nk(Sec.70K BuaOav and Pro(esslov Code:The Contractor's Llrense law
FRF dare not apply to an owner of property who Wilda or Improve&thereon,and OCC.GROUP RES.UNITS
whodoessucbworkhlmaelforthmough hisownemployees,provided that such
Improvements are not intended oroRered for tale.If,howevegthe building or TOTAL:
Improvement is sold within one yearofcompldlon,the owner-bu0derwiB have
t41.4urden ofpmvingthat he did not build orimprove forpurposeofuk.). QTy. PLUMBING PERMIT FEEFLOODZANE APN
U L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to mvmad the project(Sec 7014,Business and Prof....Code -
T le Contradoes License law dm no apply to an owner of property who
WALTER-D TEild.or Improves thereon, and who contracts for such pkojem with a RsM A VENT-WAR IEA)
dor(.)Licensed pursuant Its the Contractor's License Law. FEE SUMMARY
am exempt under Sri. B k 151P C for this reason BAIX FLOW PROTECT.DEVICE FEES
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY - Y_ N�
WORKMAN COMPENSATION DECLARATION RECEIPTN
[::]I hereby affirm that I have a certificate of consent to self-Insure a SCHOOL TAX Y_ N_
certificate of Workeri Compeveduss uranceara cenHied copy thereo($ec. - RECEBtT0
MOO,Tab C.) }C,,AS r" -t.W.
PARK FFP Y_ N_
Corry nr Y"' .Sy .O ) RF-CELPTN
9 BUILDING DIVISION FEES
Certified copy b hereby with
the city
Certified mpysfiled with the dty Wpe Tion divlelon. CRGSEIIQ5 EPT R PLANGI-IECK FEE
CERTIFICATEOFMMPEION FROM WORKERS'(,,,_. ETRAP PAID
COMPENSATION INSURANCE
(fhbsectlon need net becompleled lithe permit bforonehundred dollars SEWER-SAMTARY.SIDRM EA.200Ff. Dale Recml ted
(5100arless.) WATER HEATFRW/VENT/F1.ECTR ENERGYFEE Y N
Ill net rdlythat
persmanrenfthenneksoastotth�spermBl&Ito0;
1 shall not employ any person in any manner n n to became subject to the WAITR SYSTEM/TREATING
Workema'Compenatlon laws-I California.Data � PAID
O Z Applicant
Z O NOTICE TO APPLICANT:If,after making this Credit /e o(Exemptlon,you NEW RESIDENTIAL PLMB.__SQFC Date Recei ted
=ldytmZ subject to the Workers''Compensation provisions of the Labor TOTAL:
cc y Code,you wort forthwith comply with such powbooru or this permit aball be
W > deemed revoked. BUILDING FEE
a G CONSTRUCTION UENDING AGENCY SEISMIC FEE
I hereby a(Ormthat therebamvtmctlon lendingagency(arthe perform- ELECTRIC FEE
Q anre o(lhe workfor which this permitH W
t ued(Sec.3097,Civ.CJ T
U _ Ie.d.e.Name PLUMBING FEE
IL I— ].enders Address QTY. MECHANICAL PERMIT FEE
O u Imnifythatl havereadthlsapplicatlonand statethdtheabove tiformMECHANICAL FEE
ation
ILIs correct.I agree to comply with all city and county ordinances and date laws PERMUISSUANCE FEES PAID:
} U) relating to building comutroction,and hereby authodu repreantatives of this
F Z city to enter upon the above-martiorad property for Wpection pu rposes. ALTER OR ADD TO MECH. Date
V — (We)agec to ave,Indemnify an d keep harmless the City of Cupertino P
RetCtted
agenot Liabilities,ydgmenls,ends and expenses which may In any way accrue AIR HANDLING UNIT CIO 10,"CFM) SUBTOTAL:
age bduaid City In mo.q.. oftq a granting d this permit,
9/9/92 AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Appilcant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applies rat or future building onvpant atom or hand le hazardous BEATING UNIT(TO 100,000 BTO) Date Recti Ile
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Cade Section 25532(a)1 HEATING UNIT(OVER 100,000 BTO TOTA
❑Yn No
Will theappllcaet or tore building ccopant use equipment or devices VENTILATION FAN(SINGLE RESLO) ISSUANCE DATE
which emit haze of w.alt contaminants as defined by the Bay Area Air
uIlty Management District? BOILER-COMP OLE'OR 100,000 BTU)
LL Yn ❑No
IFuvereadlhehavrdo. materi4lsmquimmensunder Chapter6.95of BOILER-COMP(OVER 100,000 BN)
it.California Health k Safety Code,Sections 25505,25533 and 25536.I
understand that iflhe building don not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQFT A
responsibility to notify the occupant of the requirements which most be met A
prior to issuance of a Certificate of Occupancy.
.� .,a --
Owner oraulhoritedagent Date WIfy
TOTAL: y I I YW �a,�,�
f
OFFICE COPY 1II11vu