24346 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro act IJentlfkatlon PERMIT N24346 '3 4 6
Building Aaare.a:
00 O Moss Qt.1L
Ower'.Name: n
✓(rte ITY OF CUPERTIN&BUILDING DIVISION
APPLICATION / PERMITA Ire / mer• BUILDINGELECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROLN
FAPPUANCES.RFADENTIAL
CTRICPERMIT FEE BUILDING PERMIT INFO
Addmec CE ❑ ❑ ❑ TLICENSED CONTRACTOR'S DECLIheretiyafftrm that l am licensed under pmvi.lonJOB DESCKB'IIO
IngwlthBenfon7000)of Dh,IsJM3o l Attest ere and Pfoul on.Cod e,and my
license isle y(y�aqde!(eadoy UP ELS
TO2
License V
Date _ed,LLIc.N C^Nr
acta
ARCHITECPSD CLARATION 201-1000 AMPS
NZ I understand my plana shall be used u public record.. OVERIOOOAMPS SQ.FT.FLOOR AREA f/SQ.FT.
Fi Io Liwmed Professional SIGNS ELECTRICAL
GG�i OWNER-BUILDER DECLARATION
�+Ij
I hereby affirm that I am exempt from the Contractor's bldLawue . w for theSPECIAL CIRCUIT/MISC
followingreason.(Section70315,Buslmssand Professions n, Code:Anycity it
O � TEMP.METER ORIOLE INST.
K� co .1meteh rcqulreea permitto tonatroct,a theAprovgdennBah permit
any structure prior tostatement
It.that
he
Ikeeze lm pursuant to the rovisih s,of e yyygg DEVICES
O � the a signed statement that he V Ilcenud pursuant la the provlslom of the
Contractor's Licenselaw(Chapter9(ou.AdngwlthSectlon7W0)ofDivlN At-
{{{...'3 sion3o(theBwlnusand ProfemWm Code)orthatheleexemptthcmfromand SWLfhINC POOL ELECTRIC VALUATION
�.'N the ba.l.for the alleged exemption. Any violation of Section 70315 by any T E R
QR applicant fora permit aub)ects the applicant to a civil penalty or eat m mthan OUTLETSSW[TCIiFSFIJtTUR
fivehundredner of he Pr. $Q}7, TYPE CONSTRUCTION
� NEW RESIDFMIAL ELECTR
�n ❑e ere owner of the properly,or my employees Is
with wage a their sole
G rompen.70Kution,w0kense.Ad Pref t..Code:Te Contracted or offeredLaw
❑ does e(net 7064,to an owner Profmiana Code: Contractor's LIcenae naw
whodo net apply loan owner orproughhis mem.orlmprwvidedws that such
OCC.GROUP RFS UMTS
whodmeauch am s himselfde through his am employee,provided that euch
Improvements sunotnNenone earofredforule.thh er-p cider ldingve TOTAL
Improvement pros within hat he did
orJuprove for purpose of Ashave
t ben of..,of
the
property,
Cr' exctruslyco fnrpurpoaeofu@J. QTY, PLUMBING PERMIT FEE FLOOD 7J7NE APN
Lj 6 as owner of the property,em exclusively Business
nd Pro with ns Codd
rontrecttn to ronalroctthe project(Sea 7061,Buelnm and Pto(mbna Code: PERMfT LSSTlANCE
The Commetoes License Law does net apply to an owner or property who ALTER-DRAIN kVENT-WATER(EA)
builds or Improve thereon,and who cormads for such p;."with a
r9a4actods)llmnaed pursuant to the Contractor's License Law. BACK PLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B A P C for this maven
veeA
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N-
• Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION pD(gvgEce PER TRAP SCHOOL TA% Y N
hereby alflmn that I have•wrtl0cate of consent in self-Insure,w a RECEIPT N
AlabCJf rkeni Compemtllonlnauranceora certified ropythereof(Sec. GAS�EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
380),IabC7\.9_w/1/J�'f/(J-a/}�� 1
PoltryN CJ�"' l-1" !/ C 7! G� RECmxI•M
Com an GAS EA.SYSTEM-OVER 4(EA)
y BUILDING DIVISION FEES
cert ed cdIIiy bhereby tum
led copy k filed with theecity
inspection division. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
ty
CERTIFICATE OF O(EMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SAM.I•ARY-STORM EA IWFI. Date Remi tat
(This section need net be completed lithe permit Isfor em hundred dollars
($100)orinu.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I mrtify that N the performance of the work for which this permit In blued,
I$hall not employ any person in any manner An as to became subject to the WATIBR SYSTEM/TREATING
Workers'Compenatlon laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL I'LMB._SQFT. Date Recel itl
Z O NOTICETO APPLICANT.It,after making this Certificate of Exemption,you
Hshould become subject to the Workers'Compenstlon provisions of the Labor TOTAL'
a. N
Code,you=at forthwith comply with such prosdsiona orthk permi/shall be
W 7 deemed revoked. BUILDING FEE
a C CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyaf0rm that there V a ro.tmmim lending Ag.my far the perform- ELECTRIC FEE
Z anceoftheworkforwhkhth6P"tb Lwd(Sea3097,CIv.C.) TOTAL:
FJ O LandAe.N.or• PLUMBING FEE
IL — La.aceAAaares. CITY. MECHANICAL PERMIT S MECHANICAL FEB
O W Icedifythatl have read this application and statethat the above lnformatim
EL Iscorma.Iagree to complywith all city and rountymcho.smand nate laws PERMITISSUANCE FEES PAID:
fA relating[o bulltling mmtmctlon,aM hereby mMarize reprcaentativee of thin
F Z city to enter upon the alsovo-mentiuned property for Inspection purposes. ALTER OR ADD TO MFLH. Date ReeCl IN
(We)agree to save,Indemnify an d keep harmim the City f CupeAlC
ago
lnrt liabih a menta,anis and expenses which may Ina way ttve AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL:
agalmteaId i ns ante a(thagrantingoflhis pe �t.
RHANDLING UNIT(OVER I0,000CFM) CONSTRUCTION TAX
Signature ! cat n tactor i D(HAUSTHOOD(W/DLKT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the Applies
or future building occupant store or handle hazardous HEATINGUMT(TO100,(I000TU) �� Date Recti tq
material as defined by the Cupertino Municipal Code,Chapter 9.IZ and the
Health and Safety Cade Section25532(a)? HEATING UNIT(OVER 100,000 BTU) TO A
❑ Yee No
Will the applicant or lure building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air rontaMnanb as defined bythe Bay Area Alr
ality Management District? BOILER-COMP OIIP OR 100,000 BTU)
•: �Yea he Q No
havea caith&S futyCodefa ccklos renrnqundeand 255rG95 of ROE.ER-COMP(OVFR 100,000 BTU) (� B
the CaliforniatandtHealth k Safety Gods,Section75505,ve a tenant,,that it
unders
.p.manlityt.hat ftifyth,building does.ith currently haveawhithatitbmy NEW RESIDENTIAL MCCIi. SQfT.
mpanalhillty to nmlfy the ottupant of the requlrementa which must be mct
pAw to issuance of a Certificate of Occupancy. NOV . 6
VV 1992
Owner or authorised agent Date
TOTAL: r� iSSUENBX:I./Lbt s
OFFICE COPY