23036 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Prom Identification 7777 PERMITNO.
Balo&5 MOIN Wav 23036
e INme: ane:
(.0 q96- �3ZJ APPLTCAIIONSUBMIl IAL DAM-
CITY OF CUPERTINO-BUILDING DIVISION J^
G a h� m.Na' APPLICATION I PERMIT l (O
Ae,hlled/ nr. BUILDING-ELECTRICA4PLUMBING•MECFIANICAL CATP.GORY CONTROL M
L4.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Adarca.)19 1 n . L#b► �- .
PERMITISSUANCE
.LICENSED CONTRACTOR'S DECLARATION El ❑ El
I hereby affirmthal l am licensed under prnvklans of Chapter9(commen& APPLIANCFS.RESIDENIAL JOB DESCRIPTION
ingwith Sectkm7000)ofDlvlsion3ofthe Businessand ProfessionsCodeand my - -
Iiom Il In o died. PANELS P
Limn s Lo tl n� a1 /+
Dale Centador / (� ,/ C
ARCHITECI'SDECLA ION 20140DOAMPS
q�+Nz I understand my plans shall be used as public records OVERIMOAMPS SQ.FT.FLOOR AREA N/SQ.FT.
kod Licensed Professional _ SIGNS ELECTRICAL LED
<LL OWNER-BUILDER DECLARATION N A
�a SPECIAL CIItCNT/MISC R
p., Thereby.(firm that l am exempt fromthe Contractor's License Law for the
P VT
02 following....(Wdi.n70315,Buslneesand Profcsslona Code:Any city or TEMP.METER OR POLE INST. O (� n
countywhich requimsa permit Mconstrud,alter,Improv,demollsh,orreuir ,V'
Q anystructure pdormits Issuance,also requirmtheappBantforsuch permitto POWER DEVICES f
E5 O Ole a signed statement that he k licensed pursuant to the pmvisloro of the t Q 9
461 Contractor'.License Law(Cha er9(commencin with Section 71X10)of Divi.
X65 sion3ofthellusines and Pmf.lmuCode)m ilud he kexempt therefromand SWIMMING POOL ELECTRIC
O X the bask for the alleged exemption. My WOIatIon of Section 70)15 by any OUTLETSSWITCI IFSFI%TURFS
appears(tau permit aubjedsthe applicant to a civil pealty M nd more than
(Iv,gbsans ed owner of (epm SQPT, STORIES TYPE CONSTRUCTION
'9..' I_I L d owner of the properly,or my employees with wages a their sole W RESIDENTIAL ELlCTR
C�y compensation,will do the work and the structure is not intended or offered for
sale(Sec.7004,Business and Professions Code:The Contnict ea License law
�$ does not apply to an owner of property who Wilda or Improves thermal,and OCC.GROUP RES,UNITS
who does such work hlmeelfortheaugh his own employees,provided that such
Improvements,are not Intended oroHered for sale.If,however,thebuildingor TOTAL:
improvement k sold within oaeyearofoompidlo,the owner-builderwill have
tl .Iftrden of proving that he did not build or Improve for purpose ofsale.). Q1Y, PLUMBING PERMIT FEE FLOOD ZONE APN
u 1,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the pmj ct(Seo 7044.Business and Profesioru Coda:
The Contactor.Llrens Law don not apply to an owner of property who ALTER-DRAIN kVENTWATER(EA)
Wilds or improves there - -
on,and who contracts for such Inpicea with a FEE SUMMARY
cgpJLadulW licensed pursuant to the Contndo's License Law. BACK FLOW PROTECT.DEVICE 5I am exempt under Sec. B k P C for this moon
DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y 'N
Owner Date RECI3171
WO RK MAN COMPENSATION DECLARATION FD(TURF_S PER TRAP SCHOOLTAX Y_ N_
hereby affmm
that I have•certifiore of cones(to xR-Neuss,ora RECEIPTOa
ce steo'Workers'CompewHonli mnmaramnifie mpythe.f Sae. GAEA.SYSTEM-1 INCA PARK Y N
3800.Leb C. PII��^ S ITB RECEIPTN
Poliryp 04L. — GAS EA.SYSTEM-OVER4 BIA)
Com nv BUILDING DIVISION FEES
Certified copy is hereby te
edified copy k feed withh the city
inspection division. ASE CRE /WDUSML WASTE INTERCEPTOR PLANCHECKFEE
ty
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA FIOFT Date RC i tN
(TMasedion need sat ba completed if the permit k(ozone Fundred dollars
(Slm)crles.) WATER HEATER W/VENT/17.I:CTR ENERGYFEE Y N
I certify that in the perf..nce of the wok far which this permit la issued, —
I shag not employ any person In any manner an as to became subject to the WATER SYSTOs(/TREATING
Workers'Compen.rtion Taws of California Date PAID
icant
_Z 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,You NEW RESIDENTIAL FILMS. SQ.FT. Date RCCCI tN
should become subject to the Workeri Comperuallon proisioru of the Labor TOTAL:
F H Code,you mu at forthwith comply with such provisions orthk permit shall be E
> deemed revoked. BUILDINC
W C CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyafOrmthat there is a construction lending agency(cribs perform ELECTRIC FEE
D Z anre of the work for which this permit k issued(Sec.3097,Clv.C.) TOTAL:
O O Lender'.Name PLUMBING FEE
IL I— Lender'.Add.
QTY. ,MECHANICAL PERMIT' FEE MECHANICAL FEE Q
OW IceAllythutl have read thisappllcad ..r ulatatethattheabove Information —�
1 IscormoLI agento comply with all city and countyardlnanaa and tlat.laws PERMITISSUANCE ,� FEES PAID:
N relating to building constroctlon,and hemby authorize mprnenlaun.f this
H U) city to enter upon the above�mentlnried property for inspection purpose. ALTER ORADDTO MECH.
_ (We)agree to save,Indemnify an d keep harmless the City of Cu ped iso Date RNCCI tM
aga4utbabWties,judgmints,"sand expencawhlch nayln anywayacnue AIR HANDLING UNIT CFO 10,000CFM) SUBTOTAL:
a al obi Clty in con arts grant) gait bpertnitAIR HANDLING UNIT(OVER 10,0OO CFM) CONSTRUCTION TAX
Ig 1—o pp ' Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUSM TE ALSDI CLO URE
Will the applicant or future build) occupant ata rhandle hazardous HEATING UNIT 100,000 BTU) �. DatC Recei tN r
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the
1le❑a 11 Yaannd Safety Code Section 7553zW2)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
No
Wllltheapplinalue fu lurebuildingaaupantusequlpmeaord.vices VENTILATION FAN(SINGLE RESID) ISSUFNX PE'E
which emit havrdous air mnlamlrana as defined by the Bay Area Air
Quality Maragement District? BORER-COMP 0HP OR 100,000 BTU)
Thave read the hazardous materials requirements under Chapter 6.95 of 1 BORER-COMP(OVER 100,000 BTU) JAN 16 1992
l the California Health k Safety Code,Sections 25505,25533 and 25534. 1
understand that if the building don not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT.'
responsibility to outlty the occupant of the requirements which most he met CITY OF CUPtH I INU
prior to Issuance of a Certificate ofOcsupancy.
Owner or authoriad agent Date ISSUED BY:✓447%
OTAL
OFFICE COPY