22479 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pmic, Identification PERMIT NO.
build Ing Address: 2^4 7 A
X0212 n/, PORTA /�
LI/c GG lM/
ware ansa: �yt1 e/1 A
Mt-8 /Lly:r. /`10A I ` 3CITY OF CUPERTINQBUILDING DIVISION Z Z p
Contradora Nama: Lie.No: APPLICATION I PERMIT C
Architect/Englneer. Lic No: BUILDINGELECTRICALPLIMBiNG-MECHAMCAL CATEGORY CONTROL, / 1
FyrG N LI SLo Se rl<es BUILDING PERMIT INFO(�
79 2 �✓ MC�)P11* �(,�, QTY ELECTRIC PERMIT FEE
Address SN nal .
PERMITISSUANCE (�'
LICENSED CONTRACTOR'S DECLARATION
Iharcby afflrmthatlam llcrnand under provolone a(Chapter9(oommen APPLIANCES RESIDENML JOB DISC ON
InenseiSection force anDlWdm3o(theBuelnessand ProlessloneCodc,sort my - /�1T—� ��v p�
license b in full fors and riled. PANELS r` C.
License ClassLk.N ,•
Date Contractor t-77Q V—
ARCHITECTS DECLARATION 201.1000 AMPS
reZ Iunderstand my plans shag be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA 5/SQ-FT.
O
Licensed Professional SIGNSEL.FLTRICAL
6 OWNER-BUILDER DECLARATION
a SPECIAL CgtCUIT/M15C
ZIhercbyafRrmthatlamexempt from the Contractor'sLicense Law for the
oo Q owing reason.(Section 70)15,Business and professions Code:Any city or TEMP.METER OR POLE INSC
r
following
z^ty county which requires a permit to construct,altep Improve,demolish,or repair
3 any structure prior to its issuance,also requires the appScant for such permit to
file a signed statement that he la,licensed pursuant to the provbloru of the ]OWER DEVICES
0 w Contractor,License law(Chapter 9(commencing with Section 7000)of Dlvl-
t,�Os slon3 ofthe Business and Prefemlo"CodOmthat he isexempt therefromand SWIMMING IDOL ELECTRIC VALUATTQCI�/
g a the basis for the alleged exemption. Any violation of Section 7071.5 by any O OII7LE.ISSWLLCFiFSFTXiTfRFS t /
g appllnnt(ora pertNt subje is the applicant toatlWl pevlty door moreHun a f
a five hundred dollars(SSDD). NEW RESIDENTIAL ELECTR_SQ.FT. STOW• E UCTION
�n ❑I,as owner of the property,or my employees with wage,as their sole
t compensatlon,wllldo the work,and thestmeture is not intended or offered for p14 G.Y.
$ O sale(Sec.7064,Business and ProfessionsCode:The Contractors License Law
does not apply to an owner of property who builds or improves thereon,and
who does such work himself or through Ne own employees,provided that such
Improvements are,not Intended or offered for safe.If,however,the build Ing or TOTAL: v
Improvement lsaold withinone yearofcompldion,the owneabuilderwill have 4`
thpmren of proving that he did not build or improve for purpose of sole.). QTY. PLUMBING PERMIT FEE D 0
�X—}s72,1oae owner of the properly,am exclusively contracting with licensed PERMIT ISSUANCE O D
contra �to--mod the project(Sec.7064,Business and Professloa Code:
The Contnctor'n License Law don not apply to in owner of property who ALTER-DRAIN&VENT•WATER[FA)
Wilds or imp ovn thereon,and who contracts for such projects with a
�gR(6actor(a)gcensed pursuant to the Cmtndors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B k P C for this cession
DRAINS FLOOR.ROOF,AREA,COND. SANITARY Y N
OUTSIDEFEES
Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION Fp(TURE&PER TRAP ,+�—� 5CIT(X)L TAX Y N
❑f hereby af( that I have•certificate of consent to self-Hare,or w RECEIPT p
certificateo(Workers'Comperuation Insurance or a certified copy thereof(sec. CAS EA.SYSTEM•I ING OUTLETS PARK FEE Y N
3800,Lab C.7
Policy p CAS FA.SYSTEd-0VER I(EA) RECEIPT if
Com any Ly� BUILDINGDIVISION'EES
Certified copy ls hereby ed.
Certl(ied copy lsllfed withth the
city Inspection division. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECIC FEE
❑ e -
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP IPAID 19
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200Pr. Date Reset t#
(This secilon need not hacompleted if(he permit lsforone
hundred dollars '
(S7000mim.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I certify that in the performance of the work forwhlch this permit is issued, TO'f1
I shag not employ any person in any manner n n to become wboa to the WATER SYSTENI/TREATING \1
Workers'Compensaticn Laws of California. Date PAID
C) Z Applicant
Z O NOTICE TO APPLICANT.If,after making this Certglate of Exemption,you NEW RESIDENTIAL PLMB._SQFT. Date Recei t#
Hshould become subject to the Workers'Compensation provisions of the Labor TOTAL: 06.70
tl2 Code,you mustforthwith comply with such provisions
orthispemdtshallbe U D _oU
W � deemed revoked.
0 c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there ls a roatrutllon lending agency for Rha per(orrtr ELECTRIC FEE
M Z anceof the workforwhlch this permit ls Issued(Sec.3097,Ov.C.) —TOTAL, R
U O fender's Name PLUMBING FEE
LL ~ Landes Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I cemtilythat l have read thlsappliationeM statethatthe above In ws formation ^
6 Iscomd.I agree to comply with all county,city and nty ordlnancesandstate la \ PERMIT ISSUANCE ` FEES PAID:
>. relating to building matadion,and harebyauthorize representatives of this
1.. Z city to enter upon the above•mentioned property for Wpectlon purposes. ALTER OR ADD TO MECH.(We)agree to save,Indemnify an d keep harridan the City of Cupertino Date Reeel t#
O
.Hainaut liabilities,judgments,"sand expenses which may In anyway amue AIR HANDLING UNIT(1'010,00)CFM) SUBTOTAL:
agar Id City in consequence of the granting of this permit.
-l9 -91 NR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTIONTAX
gaturn of Appllant/Contacior Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appllant or(uture building occupant store or handle hazardous HEATING UNIT(TO 107,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.13,and the Date Recel t#
Heahh and Safety Code Section 25532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yrs M No
Wllltheappliant orfutum building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contamiants as defined by the Bay Arca Air
Quality Maagcmant DWrici0
7 BOILER-COMP QHPOR 100, 0 BTU)
4 Yea No
have read the 1, cause ma terialsmquimmnbunderChapter6.95of BOILER-COMP(OVER 100,000 BTU)
the California I lealth h Safdy Code,Sedlon,25505,8533 and 25536. I
understand that if the building does not mr,ently have a tenant,that it is my NEN RESIDENTIAL MECH. SQ.FT
responsibility to notify the occupant of the requirements which must be met
prior to issuance of a CertiBateof Occupancy. ax
Owner or authorized agent
Data - ISSUED BV:
TOTAL:
OFFICE COPY
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