23418 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
-Building Project Identification PERMIT NO.
Budding Address: � f"1^ /I (�
0 S� At d/S%9 2 3 4 785
enu:
ME1•,O �OG /W/ (g1 CITY OF CUPERTINO-BUILDING DIVISION
Co dor.Name:` APPLICATION I PERMIT 7-1
��"IU�O�• `y/>f// D/ BUILDING-ELECTRICALPLUMBINGMECIIAMCAL CATEGORY CONTROL#
Architect/Engineer. Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
lil,�f PULSES LIMIT
Address:/ 22 S �.gTOG/9 !/� PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby af(Irm that l am licensed under provisions of Chapter9(oommen APPUANCFSRESIDENTIAL ]OB DESCREMON
I.s.1 .fors to.of d effeon3 afthe Buslneseand ProfeasloneCode,and my �1
1 cense ie In fuR force end effect. PANELS 1 l 1
muse m Lie#
Date Coolacto UP TO 200 ANUS
ARCHITECT'S DECLARATION 2II-1000 AMPS
PQ!x ZCC I undersea my phm.hall be used as public record.. OVER ION AMPS SQ.Ff.FLOOR AREA
E od U Licensed Professimal SIGNS ELECTRICAL LED IN
den�[;u OWNEReBUILDER DECLARATIONes SPECIAL CIItCU1T/MISE T E R
7M IherebyafBrmtMt am NER-B mpt ILDER ContLicense Law(m the
Q following reason.(Section 711115,Business and Professions Code:Any dty or
F f"9countywhich refulma a permit to construct,alter,Improve,demolish,orrepair TFMP.METEIt ORIOLE INS?. ♦ g
Oa lieY-bvdm uPrlarto lot lssusnce,abo requires the applicant formch permit to ®li�G
V file a signed statement that he is limned pursuant to the provisions of the POWER DEVICES 7i
u, Contractor's License law(Chapter 9(commendng with Section 7000)of Divi. SWIMMING POOL ELECTRIC SVALUATION OS sian3 oftho Buslnnsand ProfenbnsCode)orthat helsexempt lherefromantl
yd the bash for the alleged exemption. Any violation o(Sedlon 70115 by any
0� app centfor a permit subjects the applicant to a dvil penalty of not more than OVILE'1SSWIICHESFlX'fURFS r.s O �
$ flue hundred dollars(5500). NEWRESIDP.NTIALELECTR RIES / TYPE CONSTRIIC'I'ION
�n ❑I,as owner of the property,or my employees with wages as their sole SQ.PT. TO
compensation,will do the work,and the structure,isnot Intended or offered for
Oto(Sec.7044,Butlnee and Professions;Code:The Contri does Llcerue law
$ does not apply to an owner of property who builds or improves Iherwry and
n•3.. who does such wark hlmsel(orthraugh hisown employees,provided that such OCC.GROUP RES.UNITS
improvements are not intended muttered for sake.lEhmvever,the building or T
Improvement bleold withinoneyearofcompl&ion,theowner-bullderwlll have
lltq nmdenI, of proving that he dal not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE [.Tpp DONNE ApN
LI a.owner of the properly,am exclusively contracting with licensed PERMITISSUANCE
contractors to construct the project(Sec 7044,Business and Profenions Code: �^
The Coomome.Llcene Lw does out apply to an owner of property,who ALTER-DRAIN&VENTWATER(EA)
Wild.or Improve - -
thereon, and who contracts for so& p(ojeats with a FEE SUMMARY
�a
dur(s)licensed pursuant to the Conmetces License Law. BACK FLOW PROTECT.DEVICE
I am exempt under Sec. B&P C for this reams OUTSIDE
FEES
Owner Date DRAINS FLOOR ROOF,AREA,COND. SAMTARY Y N
re or RECEIPT WORKMAN COMPENSATION DECLARATION FIXTURES-PER IRM SCIdOOL FAX Y N
❑i hereby affirm that I have a lmumne of consent d pythe �a RECEIPT X
M00,IcenifibC.Worker(Comperwtlon Wurance oram�rtlYfled copy thereof(Sec. GAS EA.SYSTEM-1 INC.4 OUTLETS
3$cy#b CJ C1936 SSFl` 90 _ PARK FEE RECEIPT
p
Cam an GAS EA.SYSTEM-OVER
y BUILDING DI V ISI ON FE CS
Certified copy is filed hereby
the
GREASE/1NDU5TRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certeled copy ot filed with 1M dty inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.XIOFT. Datc RCCCI tic
(Ihlsecdlon need not M completed lithe permit ot(Drone hundred dollars
($10D)or len.) WATER HEATER W/VENT/ELDCTR ENERGYFEE Y N
I certi(ythat in the performance otthe work for which this permit is Issued,
I.lull not employ any person In any manner an as to become subject to the WATER SYSTEM/TREATIN'G
Worker(Compensatlon Laws of California, Date PAID
z Z ApplicaNOTICE
NEW RESIDENTIAL PLMB. SQ.FT. Date RCCeI tic
Z O NOTICE TO APPLICANT:If,after making this Certificate of exemption,you
should become subject to the Workere''Compematlon provisions ofthe Labor TOTA :_
C N Code,you must toldhwlth comply withauch provisions or this permit shall be BUILDING FEE
W > deemed rovoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Ihereby.01 that there h a commIction lending agency for the pedorm- I ELECTRIC FEE
Z once of the workfar which thispermitot Luued USec.3097,C1v.C.) _a
02 Lender's Nana PLUMBING FEE
LL ~ Lender.Addreea QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW (certify that]have read this application and statethatthe above lnfamutlon
a Iscorred.i agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEE$PAID:
} W lating tobWilling construction and hereby authorize mproentativm o(thls
(_ In cyto enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
V agree to eve,Indemnify an d keep harmless the City of Cupertino Date RCCCI tJI
alnst llabBlticsjudgmmbts, de .which may in anywayacemu AIR HANDLING UNIT(TO IftWO GEM) SUBTOTAL;
gairut uid Cl cone (the rating of this pertnlL AIR HANDLING UNIT(OVER IQODOCF'M) CONSTRUCTION TAX
I rcof App rat ra or IJ a EXHAUST HOOD(W/DUCT, CONSTRUCTION TAX PAID:
H RDDUES MATERIALS DISC SUR
Will theappllcant refuture building omvpant.tomor handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCCCI t�
material as defined by the Cupertino Municipal Code,Chapter 9.l$and the --
I Iealth and SafetyCade Sedbn 25532(a)? HEATING UNIT(OVER 100,000 BTU) T T
❑ Yea rl No
Will the appilmnt c_rTuturc Wilding occupant use equipment or devimVENTILATION FAN(SINGER RESID) ISSUANCE DATE
which emit hazardous air tontamise nts as dented by the Bay Area Air
Quality Management District? BOILER-COMP DEMOR 100,"BTU)
4Yea n No . PAID
havemedthe haza�ousmatedabrequiremientsunder Chapter 6.95of BOILER-COMP(OVER I00,OOf)BTU)
the California Health&Safety Code,Sections 75505,25533 and 25534.I r�
understa rad that if the building does not curmstly have a tenant,that It b my NEW RESIDENTIAL MECH. SQ'IT' LIAR 0 1992
responsibility to notify the occupant of the requirement.which at be and
prior to issuance of a Certificate of Occupancy.
v
Owner or authorized agent Lill Wit• cut- n
Date ISSUFI] -
OFFICE COPY