21987 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ect Identification 7 PERNET NO.
Building Address: n a� n n
)05&V ?WAP— t-HV98
P Delvr< G I
where ams: ane:
3EFF2Ey P. SUTrea_ CITY OF CUPERTIN&BUILDING DIVISION
Contractar'sName: LIc.No: APPLICATION / PERMIT
IE.LFCTQC+ C IO 549(.03Z SUMDING-ELECTRICALPLUMBING-MECtANICAL CATEGORY CONTROL.
Architect/Engleeer: Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: POWTISSUANCE O o
LICENSED CONTRACTOR'S DECLARATION
I hereby
emthansedunder proWomter9(co
IAPPI]ANCESRF9DENTUL
leSccflonf Division 3 ofthe BugnessandProlmdonCode,and myLJOB DESCRIPTION
license i ll forceAsod effect. PANELSLIcarscCIms
Glc M
Date Contractor UP TO 2DO AhU
ARCHITECTS DECLARATION 201-[000 PS
q�q�uu mO Zp I understand my pisco shall be used As public record. OVERIOWAMPS SQ.FT.FLOOR AREA $/SQ.Fr.
Fi Licensed Pmfesalowl SIGNSELECTRICAL
<jn.4 OWNER-BUILDER DECLARATION SPECALCIRCUIT/MISC VU
. F, I herebyaffirmthat l am exempt from the Contractor's License Law for the
following reason.(Section 7031.5,Business and Professions Code:Any cityor
rI"u { muntywhlchmquimsaper ttomrutmat,alter,impmve,demolbh,ormpalr TEMP'METER OR POLE INST.
S� a anystructure prlorro its lssuance,aiso requlrnlheappBmnt for such permit to
P5 file a signed gatemen,that he is licensed pursuant to Me provisions of the POWER DEVICES
wSOContradors License Law(Chapter 9(comSWIMMING POOL ELECTRIC 01
VALUATION
mencing with Section 7000)of Divi-S 1.01 ellhe Bgn
uessand Profeau b fioCode)orlhat he exempt therefromand
$ the Web for the alleged exemption. Any violation of Section 701L5 by any OUTLETSSWITCHIESFTXTIIRFS
applicant for a permit subjects the applicant to a civil penalty dnot more Than
fiv6milred dollars(¢AO.
NEW RESIDENTIAL ELIGTR SQ.FT.
�n
1,as owner of of property,orhe employees inwithwages r thelesob STORIES TYPE CONSTRUCTION
compensation. ilmshoatmcturebnot Intended License Law sale(Sec.apply ply Buan ow er Professions Code:T W orContractor.
ove,Licene Law
does whodossachtoanawnerofthrougywhabuildsar0mprwesdhareoryand OCC.GROUP RES UNITS
CC whadoementsworkMmsendedomughhbownle.ILh ts,provided wtverthebuil atsuch
Improvement are not Intended aroffered for sale.I(,howeveq thebullding¢ TOTAL:
improvement twldwlthln oneyearafcampIdiogtheowner-bu0derwlll have
t enofproving,hathedid not build or improve for purpose of ule.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
L a owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractorsto comtmetthe project(Seo 7044,Businessand Profeulore Code:
The Contradors License Law dm not apply to an owner of property who ALTER-DRAIN&VFM-WATER(EM
or improves thereon,and who contract. for such pi with a
ogOS(acha*)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
L,J I am exempt under Sec B h P C for this reasonOUTS I DE FEES
DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y N
Owner _�nDate — — RECEIPT R
OMPENSAI'ION DECLARATION FIX.�S��, SCHOOL TAX Y N
❑I hereby ark that,I have o imus to of consent to pythe re,(S , RECETT«
3800,UbClWarken'Comperoatlan lruuranceora certlflnd copythemof(Sec. GAS IA.SYSTEM.11NCAOUTLEfS PARK FEE Y N
polis Lab C.I
Polity n RECGAS EA.SYSTEM-OVER 4(FA) DING DT p
CR
BUILDING DIVISION FEES
L�Certified copy b herebyth the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy b pled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA. Date Remi [#
0hissection need not be complged if the pemdt b forom hundred dollars P
(f100)orlessJ
I ce.I...)t In the pe0arnunce o(the work I.,which this permit le,suedWATER HEATER W/VENT./ELF.C'TR ENERGYFEE Y, N_
I shall not employ any person in any manner so u to become subject to the WATER SYSTEM/TREATING
Warken'Campenmtlan Laws of Glllamt.Date PAID
O Z AppliNOTICE
NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
Z 0 NOTlCEcomembjci I.
e after makinrs'Co this ation ateaf Exemption,you
Code,shoulyou
Rme surthwit ,co Workers'such prvisinprovisions his permit
shall
TOTAL:
a. W CodGyau mugforthwlth comply with such pmWlom or this pemdt�hallW BUIN 'E
7 deemedrevaked.
0. — CONSTRUCrION LENDING AGENCY SEISMIC FEE
d I hereby affirm that there is a mrutmction lending agency for the perforrry ELECTRIC FEE
D Z ansa of the work for which this permit b Issued(Sec.3097,Civ.C.) TOTAL:
V O Lender's Name PLUMBING FEE
LL ~ LmdcreAddmea QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I certitythal l have mad thtappliatio...d palethattheabavelnfarmatlon
,correct.I agree to complywlth all city and county ordinances and gate laws PERMIT ISSUANCE FEES PAID:
} IL N relating to building construction,and hereby authorize representatives ofthb '%Z 1 //'�
H Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,Indemnify an d keep harmless the City of Cupertino Dale Recei t#
U against liabilities,judgments,cogsand expenses which may in any way acme AIR HANDLING UNIT(T010,000 CFM) SUBTOTAL:
against mid City In son R.of the granting of this permit -
n AIR HANDLING IJNTf(OVER 10,0gCFM) CONSTRUCTION TAX
`� 2
ljs -, _- � 4f'Z-9 I CONSTRUCTION TAX PAID:
Sig p0 1/Contractor Date E)(HAUST HOOD(W/DUC'O
HAZARDOUS MATERIALS DISCLOSURE
Will the appllc dorfuture building occupant store or handle hazardous 11EATING UNIT(TO 100,00)BM Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
Health and SafetyCade Section25532(a)T HEATING UNIT(OVER 100,000 BTU TOTAL:
❑ Yes No
Will the applicant or uwmbulldingmmpantuucqulpmentordevims VENILATION FAN(SINGLE MID) ISS ATE
which emit harardous air cclumdmnt as defined by the Bay Area Air
( lily Management D❑btrict7 BOILER-COMP OHPOR 100,000 BTU)
Yes
have read the hazarclousomateriab requirement underChapter 6.95 of BOILER-COMP(OVER 100,000 BTU) �� 9. 1991the California I Iealth k Safety Code,Sectlmes 2S505,25533 and 25534.1
and moand that if the bu doling does not cu rrently have a tenant,that It Is my NEW RESIDENTIAL MECH. SQ,FT
responsibility to notify the occupant of the requirements which must he met
poor to Lssumor of a Certificate of Occupancy.
Owner or authorised agent Date ISSUED
TOTAL:
OFFICE COPY