23700 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification I PFRMTTNO.
Building Address: O �,2 �,,0�;,N 23700
n R.("o�y
Phone: APPUCATIONSUMnTAE=A .
(�J p�f f a,l CITY OF CUPERTINO-BUILDING DIVISION
can n cm, N. LIc.No. APPLICATION /PERMIT
BUfLDING-ELECTRICAL-PUIMBING-MTCHANICAL CATEGORY CONTROL#
ArcMted/Engineer: Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRunder rDECLARATION
I herecrfiorr70 that 0).f l.3.funderpro.a.dso(.i.p.0 d,com enc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Inense Is Infon7000)o(DiWNon3 ofthe0uslnessand ProtemloneCode,and my /aa � �
license Is In full(orae and effect PANELS v(V\
Licence Chat le.If
Date ContractorUP TO 200 q
ARCHITECTS DECLARATION 201-1000 AMPS
Q]_ Iunderstand my phtushall be used as public records. OVERIDOOAMPS SQ.FT.FLOOR AREA S/SQ.FT.
O
zLicensed Profivedoral SPGNSELECTRICAL ' E D I O r
¢' OWNCR-BUILDER DECLARATION SPECIALCMCUIT/MISC
F., 7 I hereby affirm that l am exempt from the Conrsdo's License law for the -- p p y� p�
IO P F. following reason.(Section 7071.5,Basin.and Profeaalons Code:Any dry or I R 9 I 4-�
cwntywhkh requlreaparMetocowtrvct,ilter,Unpmve,demoldh,orrepalrTIMP'MEffR ORIOLE INS(. V
pLI�Ct.I n Vudure rumto its issuance,alsorc Ireathee lion foreuch permit to
mm Y• P 9's. tt Ice RAWER DEVICES
C X¢) file a signed statement that he b(ChapterLaw licensed(cont pursuant to the provisions of the
3"�n Con3ofthLicem and Prfmio9(mmmendathng ehS mpt hemfmfDiel- gwQs.{hgNC I00L ELECTRIC VAL ON
O smn3o(the Businnsand Profemiom Code)orthat hebexem therefromand
g y.'
the bash for the alleged exemption. Any violation of Section 70715 by any OUTLETSSWITCIIF_SFIXTURFS _--
OO
applicant fora permit subjects the applicant to a civil penalty of nor mom than S00
(vc dred dollars(y.500).
s owner of the property,or my employees with wages as their sole NEW RESIDENTIAL ELTCTR SQ.FT. STOW ES TYPE CONSTRUCTION'
co%pen,ation,, cth wfll do the work,and the struure not intended or offered for
Oto(See.7014,Business and Professions Code:The Contractors License law
S S does not apply to an owner of property who W Ilds or improves thereon,and OCC.GROUP RFS.UNITS
who dues such work himself or through his own employees,provided that such
Impmvements are not Intended oroffered for sale.If however,lhebuili ing or TOTAL:
improvement Is sold within omyearofcompleioq the owner-W Oderwill have
t rden of proving that M dm not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contoctors to mu(
rrud the I rojed(Sec.7064,Rualneas and Profes• w bCode:
The Contractors License law does not apply to an owner of property who ALTER-DRAIN&VENTWATER EA)
or Improves thereon, and who contracts for such plojeds with a -
c u FEE SUMMARY
gIltfactor(s)licensed pr
Ira to the Contradc's License Law.I am exempt under Sec B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSI DE FEES
' Owner Data DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N—
RECm T M
WORKMAN COMPENSATION DECLARATION FIXTURES PER.TRAP SCHOOLTAX Y_ N
QI hereby affirm that I have a artifiote of concent to self-insure,ora RECEIPT III
certificate ofWorkeri Camperuauonlrmurance ora certlfbd copy themof etc. GAS EA.SYSTEM-1 INCAOU'rLETB PARK FEE Y N
policy
lab CJ RECEIPT a
I'. M GAS FA.SYSTEM-OVERd(EA)
C. any BUILDING DIVISION FEES
ECertitled copy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy is filed with the city trupection division.
CERTIFICATE OF EXEMPTION FROM WORK ERS' GREASE TRAP PAID
COMPENSATIONINSURANCE SEWER-SANITARY-STORM EA.200FT. Date Receipt#
(fhisseciionneednctbecompletedif hepermitbfor aro hundreddollars
($10(fiorless.) WATER FIERCER W/VEM/ELFCTR ENERGYFEE Y N
I certify that m the performance of the work for which this pemdt is issued,
1 shall not employ any person in any manner so as to become subjed to the WATIRSYSTEM/TRGTING
work o'Compensationlawsof Gllfornia.Date PAID
Q Z Applicant NEW RESIDENTIALPCMB. SQ.FT. Date Remi t#
Z Q NOTICETO APPLICANT:If,after making this Certlfkate of Exemption,you
should become subject to the workrs
e 'Compemlo
atton provism of the Labor TOTAL:
CO Code,you=at forthwith comply with such provisions or this permit shall be BUILDING FEE
W > retired revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL IherebyafRrmthat them 6 a construction lending agency for the perfomm TOTAL: ELECTRIC FEE
7 O ante cfthe work for which this permit b tasued(Sec.3097,Civ.C.)
lender's Name PLUMBING FEE
LL F lenaeh Adamaa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I certify thatl have madthb appliotlonand pate thattheabove information
M is correct.I agree to comply with all cityand county ordinances and orate laws PERMIT ISSUANCE FEES PAID:
>. relating to building construction,and hereby authorize representatives ofthis
F. N city to enter upon the above-mentioned property for inspection purposes. ALTFRORADDTOMfCH.
? (We)agree to save,Rd ' an d keepnor v the.Cl(y of Cupenlno DateRCCCjp[#gainst itbilfte.,jadgma nae. Ich may In anyway accrue AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL:
agairutsaldC In conftp anon (ttiI it.
AIRHANDLINGUNIT(OVER10,"OFM) CONSTRUCTION TAX
S w reo(A r r Data EXHAUST HOOD(W/DIK'D
CONSTRUCTION TAX PAID:
A US MA IALS DISCIASURE
Will the applicant or future build gompant store or handle hazardous [iFAnKC UNIT(TO 100,000 Bi11) Date RCCCi t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the —
IleaBhand Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) _ TOTA
Fly. , M No w
Will the applicant or future Wilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE—DATE
which emit harardom air contaminants as defined by the Bay Area Air
Quality Management Dist rid? BOILER-COMP(3FPPGR 100,0I0 BTU) MAY 18 1992
Y;s ❑No
haveread the afet materials
ection requirements aChapter 6.95 of BOILER-COMP(OVEN 100,000 BTU)
the Cilifomh at if t h&Safety Code,Sections 25505,25533 a t and 2:536.1 CT6I IIVU
understand that if the building docs not tvrrently haveamnanq that it is my NEW RESIDENTIAL MECH. JQ.FT r,IIY Ur UUF
responsibility to notify the occupant of the requirements which must be met /-�
prior to isausnce ofa Certificate of Occupancy. TOTAL.: \��s����
Owner or authorised agent Date ISSUM BY:I
OFFICE COPY