23093 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Palet Identification PERMITNO.
Bao"duo r e% C,7jT$u0 C ,.gSoi4 23093
ante: one: APPLICA HUN SUWTITA_175=
BILL p� CITY OF,CUPERTINO-BUILDING DIVISION c '
C tractofeNemd; Lk g: APPLICATION/ PERMIT �•—� C
• BUIIAINGELECTRICA MtIMBINC-MECHANICAL CATEGORYCONTROL N
A ItM glneer. Lit.Na
o� `QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO"
Addre.c Lf �' C�AJ• �+ • PIMMITISSUANCE O ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l alicensed under provisions of Chapter 9(commdnc APPLIANCESRESIDENI'IAL JOB DFSC ON
m
Ingwlth Secdon7000)of Dlvislon3 ofthe Buslneasand ProfestlonsCode,and m
PANELS
licens hIn(u ane dreg. ,a,� s /I ,g TMTn1K gq
Llcens ChoLIaN �'(f�(�` -
Date Contractor
ARCHBDE TION 201-IODOAMPS
O (understand plain aspub cmearda OVER1000AMPS SQ.Fr.FLOORAREA $/BQ.Fr.
O
U lw.stonl S(CNB ELECTRI AL T E �'—R1•
OWNER-BUILDER RATION SPECIAL CIRCNT/MLSC 1 1 '( 'J
1hereby (Rmm
anthat l aexempt hem the Contractor's Limas Law forth. - -�
following reason.(SeMon 7(315,Business and Profession Code:Antl or tt��
001-. y city TEMP.ME177t OR P06rNST. I, J I
countructme prioriraquireapemdtto mnesugdter,impmventfors ch,orrepalr -
anyatncturc itehat he is lical$ensed pursuantthe
t the pro mcons;of t e 1
y POWER DEV(
m floe a signed statement"..Lathan he t licensed pursuant ng it the provisions;a! the
3 u,y
Contractor's ursine GdPrf..t..0odtnenclathei3BetllonhemfmlDTVI- SWUAENC 6--- VALUATI(J{J
thesiobasis
for
exempt W.Code)orthathohexempttheIS by any
O the basis!or the alleged exemption. Anyviolation p Section 70315 by any b O D a O
ape hundred dolaMneubjecbihe applicant toe tlWl penityof net more than OUTLETSSWITCIIESflXTIIRFS
B
five hundred nelhrs he pr.
I.as owner of the property, NEW RESIDENTIAL ELFGTR SQFT. RIES TYPECONSTRUCTION
a ❑ p ork,a or my employer with wain as(heir woe
mI.&.70Ktica%Basin...will do workanithscincturehrat intended oroffered for
censeLw
I.(Sec.apply
to alnow and f property Code:The Contractor's License law
�,I $ dace not apply tomowrerorthrou hwho nem orImprove,
ovidedreory and OCC.GROUP RES.UNITS
M whodoem nt.am kMmtended orwghed for owns,If,ho ever,the builat such ing or
imprwemantearcnoHnterddd earo(compluh.I(,h ner-y deer buildingorTOTAL:
improvemnthwld wllAinonyearofcompldbrylheewnerbulWerw111Mve ,
th,,Lurden of proving that he didnet build or Improve for purpose ofsoe.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively cot...--g with I.—ava
mntrccturs to conlruct the project(Sm 70K Business and Profeslon Code: PERMIT ISSUANCE
The Cantnaor's Limns Law do.not apply to an owner or property who ALTER-DRAIN kVENT-WATER(EA)
Wct
builds or thereon,and who contracts(or such p4ojds with
ctor(.)Bcensd pursuant to the Contractor'.Limns Law. BACK PLOW PROTECT. FEE SUMMARY
s1 LJ I am exempt under Sec. .
B k P C for this reason - OUTSIDE -
DRAINSFLDORA,
ROOF, SANITARY Y N_
F • Owner Date RECEIPT
N
WORINIAN COMPFNBATION DECLARATION SCHOOL TAX Y N
❑I hereby artium that I have a artlflcate a(consnt to seR-Imre,ar a ?' FN S�Thr o0 RECEIPT N
certificate of Workers'Compenabon lnuranceoracertlfled copythereof(Sec.
3800,Lab CJ GAS EA.SYSIIS1f-]INCA 0UTLEffi PAW(FEE Y— N
Policy It - - RECEIPT CAS FA.SYSTEM-0VERd -
' Corn any - BUILDING DIVISION FEES
Cediried copy is hereby tthcity
e city inspection division.
e
CertBled copy h filed withh the CREASEANDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WOR K ERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Recei t#
RNseetllonn completed"'as erMth/oran M1undrandollan
($100)or les WATER HEATER W/VENT/ELFOTR ENERGY FEE Y N
(cert hat tribe orme to o�k'�I Ichthh rmithhsued, —
I.ha at employ an p pe re i y RePSo as o be..subject to the WATER SYSTEM/TREA77NG
W ra'Compens a ate PAID
O Z ppllcant / NEW RESIDENTIAL PLMB. SOFT. Date Recef t#
Z O NO ETO LOAN 1: er ihh Wleof n,you
Id beco- mbject to the Wg Com lion provision abbe Labor TOTAL:
N Code,yay�must fonhwlth comply with su -51soorthhpernutshalibe BUILDING
W j dre revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a eofthe orkfoffirm whicat h lending ency
.) perform- TOTAL: ELECTRIC FEE
•L) Z sneerlhlarras orwhichihhpermit hhsued(Esc.3097,CIv.C.) �d
LL Lenders Nemo - PLUMBING FEE •p0
LL H lend at Address QTY. +'MECHANICAL PERMIT FEE tfoa MECHANICAL FEE
0 L Irani.Iagrectothatl complye read with alcityndcmunand tyordiancesndstatethat as"
1 hcoingt building commactio ,and hereby
auharin representatives
and Wielasw PERMITISSUANCE FEES PAID:
W relating to building mntroctlon,anndproprtyfrin inspection
npurposotthh `
.r Z cltyto enfcu vo-trentloned property(or inpectlan purpose. ALTEROR ADD TO MFOfi. Date ReCel t#
„{ViE}agree to sue, demnl(y an d keep harmless the City of Cupertino P
ag.mtEabilBles,P nta,metsan hkhmaylnanywayac'crue AIR HANDLING UNIT GO 10,000 CFM) SUBTOTAL:
ag.inteaid City roes as .permit
AIR HANDLING UNIT(OVER 10,000CFM) - CONSTRUCTIONTAX
SI reofApplcan(7Contractor 01 Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUSMATERIALS ISCLOSURE
Wills applicant or future building occupant store or handle hamrdous HEATING UNIT(TO 100,000 BTU) Date Recei t#
materlal as defined by the Cupertino Municipal Code,Chapter 9.12,and the.
I leaith and Safety Code Section 25532(a)2 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yea MN.
Will the applicant orfune building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSLIeII1�C�DATE
which emit ham aloe.at,mntamiasmas.de0red by the Bay Area Air Y Fa44
Quality Management Dhe ❑istrict? BOILER-COMP DFm OR I00,IXD BTI()
• I Yes N No
M1avernia tealth& ons mode,le tions 2men,25533 and
6.95 of BOILER-COMP(OVER 100,000 BTU) DEC + 1991
the ersta d hat If the
k Safety Code,Sections 25565,have
a t and 25536.I
understand that lithe the ing doesoccupant of the require encs tench.)that it homy NEW RESIDENTIAL MF.CH. SQ,FT
responsibility ce Of a Cthe occupant ccupa the requirements which must he met /a � f C ,.a I NU
prior to Issuance ofaCenlfimle of Occupancy. yllY W NUP�It
-j
Owner or autherlaad agent Data U•V
TOTAL: ISSUED BY:
OFFICE COPY