23411 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE SALL POINT PEN ONLY
Building Project Identification PERMIT NO.
B°Ipling Add rev°;Ioo23411
�o 40-VL.G.- � r t� svi�/
meas ante: one:
CITY OF CUPERTINO-BUILDING DIVISION _C)
contra or'.Name: tl..N.: APPLICATION I PERMIT [[
Architect/Engineer. Lle.No; BUILDING-ELECTRICAL-PLUMBING-MECHAMCAL CATEGORY CONTROL p
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address Y , PERMITISSUANCE ❑
LICENSED CONTRACTOR'S DECLARAQ TION —�Y
I hereby affirm that l am licensed under provisions.(Ch.pler9(commen APPLIANCES-RESIDENTIAL OB DRSCRR'170N
ingwith Sedion 7DOO)o(Divipn3 ofthe Businesand PrefesslnsCode,and my
license bInforce ndsteer. PANELS UP TO 200 ANTS eyvLo r. ... T 1r,License Closs;e Gop
Date Contactor 201IODO AMPS
ARCHITECT'S hall CTSDECLARATION
ppp{q±ceO Zp ]undentand my p6ra stall be used spubile record". OVERIWOAMPS SQ. FLOOR AR 5/�.Pf.
&'UU� Licensed Pmfe®Iunal SIGNSELECTRICAL _3 D �Q a
OWNER-BUILDER DECLARATION / SPECIAL CIRCUIT/M15C ,DO •l
Ihereby afflrmthat l am exempt from the Contractor's License Law for the
❑ following matuon.(SeRIn 70315,Ruslnen and Professions Code:My city or
Fsy county which requires.permit to c°rorueL.ter,improve,demolish,or repair TEMP.METER ORPOLE INSC.
g°"'I 3< any structure prior to Its Issuance,also requires the appUcant for such permit to POWER DEVICES
Vi Ble a sige b ned statement that hlicensed pursuant to the provisions of the
3r` .. Contractor'sLlceme Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC OJ sion3 ofthe Business eand Profess b VALUATION
bCode)or that he
Eexempt therefrom and A �y ,d es$ the basis for the alleged exemption. Any violation of Section 70315 by any OUTLETSSWI7CHESFIXTi1RES y / D p/
pplicamfora permit subjects the applicant to a civil peslty of not room than V v
$ fl 1,as ed owner of
NEW RESIDENTIAL ELECTR SQ.FT.
STORIES TYPECONSTRUCTION
�n I,as owner of the property,or my employes with wage r there door
U mpensati44,will do the Hualre.and rfesk,and ihepmcthus is e:TheC ContraIntenctors
d for
Law
O xle(netappl toalnowandfpropelow Code The or
rimprves thereon Law
T,S $ doon'ssuclh oanownerorp roughrty who bulmpoye",provided
r anted thatand such OCC.GROUP RES.UNITS
0.0. whodceeents woramkMmtendedeIffor hroughedown e.If,hos,er,the uilding or
improvements
lnlendneyearfBred(orsalmtheo ner-b gder ilI have TOTAL:
Improvement boots within oneyearo(completlon,the owner-budderwill have
tl)5kurden of proving that he did not build or improve for purpose ofde.). QTY. PLUMBING PERMIT FEE
UFlAOD7DNE APN
4 as no,of mthe property,am 704A Business
ess contracting with Ilrenxd I PERMIT ISSUANCE -[J I
rontracton to rosW R the project(Sac 7014,Businms and Professions Code:
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN k VENT-WATER EA) /a
Wild ar Prov thereon, and who contracts for such p(ojecb with a 3 a OV FEE SUMMARY
�q➢(�.ct Bren pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE QIJIS I PIP FEES
LJ I e oder Sec B k P C for this reason
Owner Date DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N_
OR AN COMPENSATION DECLAR TION RFGF71'C p
❑I re a((Irm that I have a certificate of consent to self-insure,or a FDCR)RE-PER TRAP (� 00 SCIMOOL TAX Y_ N
RECEIPT p
rertlRat
3800,lab C.) orken'Compesationlsurana oracertified copy thereof(See. GAS-EA.gySI.pA1-11NCA OUTLETS PARK FEE Y N
RECE
Policy N GAS.FA.SYSTEM-OVER 4(EA) DING DI
Com any BUILDING DIVISION FT:ES
-Certified copy b hereby famished. GREASE/INDUSTRL WASE INTERCEPTOR
PLANCHECK FEE
Certifed copy b filed with the city inspection division.
p CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.3(DFT. DRIC RCCCI [N
t (rhb.ectianneed notbecompleted lithe permit Mfor.ne hundroddollan
(81
(ceartifyntify that tathe performance of thework f.rwhlch this permitIssued,ued, WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I shall nm employ any person In any manner n as to become subject to the / WATCR SYSTEM/TREATING
r Workers'Compensation Lawsof CallfomIa.Date 00 PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQIT. DRIB Recd ted
Z O NOTICE TO APPLICANT.If,aNer making this Certificate of Exemption,you
F" should become sub)ect[.the Workers'Compensation provision,of the Labor TOTAL;
L Code,you=at forthwith comply with such provisions or this permit shall be
Ill j domed revoked. BUILDING FEE
CL C CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirmthat there b a construction lending agency for the perform- ELECTRIC FEE
Z ance.fthe work forwhich this permit b Issued(Sec.3097,CIv,C.) TOTAU a,
V O Ianderb Name PLUMBING FEE
LL I— Lendcrb Addren - QTY. MECHANICAL PERMIT FEE MECHANICALFEE
Icedltythat l have read this appBcetlemand pate thattheabove infometiun
O W
S is correct.I agreeto comply with all city and county ordinances and pate lawn ( PERMITLSSUANCE -oO PEES PAID:
} W relating to building rombuctlon,and hereby authorlu se
reprentativn°fthb
} Z city to enter upon the abovcmentionend propertyfor inspection purpose. ALTFRORADDTOMEGH.
V (We)aale° e,indemnify
d keep hamdow the Clty.(Cupertino Date Recei
f#
ag Il
dgmeme,mstaand expenses which may in anywayacenve AIR HANDLING UNIT CFO 10,000 CPM) SUBTOTAL; •Q
a i I old Ciry In ndequence.f the granting.(this permit.
AIR HANDLING UNIT(OVER IO,ODOCFM) CONSTRUCTION TAX
SI to of Applicant/Contractor Date RXHAUS'r HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WI eappliant or future building occupant store orhandle hazardous HEATING UNIT(TO 100,000 BTU) Date Reeei IN
nxaterlal as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and SafetyCade Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes No
Will the applicant or bore'suildingwmpanluxcquipmrntordeviced VENTILATION FAN(SINGLE RESID) a� ISSUANCE,DATE
which emit harard.us air contaminants as defined by[be Bay Area Air Y N4 1 BUJ
Quality Management District? BOILER-COMP DHP OR 100,000 BTI)
4 Yee No np Q
havereadthehaza oro materials requirements under Chapter 6.95 of BOTLER-COMP(OVER 100,000 BTI) MAR 1 tD 1992
the California Health k Safety Code,Sections 75505,25533 and 25534. I
understand that lithe building don not currently have a tenant,that It b my NEW RESIDENTIAL MECH. SQ.FT
responsibility to notify the occupant of the requirements which resat be met CITY Ur CiUNCh111YU
prior to issuance of a Certificate of Occupancy.
Owners authodud agent Data I
TOTAL, ( e� ISSUED
OFFICE COPY