21602 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO,
Building Address: /"1 al 0 n
859 �2Fs�D�o D2 . G I G
orae . ante: one:
_eF_
'41
2MAA.14bt257d93 CITY OF CUPERTINO-BUILDINCDIVISION
Carta asshlank: 61a.No: APPLICATION I PERMIT
K 4
�) J MA5D,d2Y SoNJ� 6 BUILDINGELECTRICALMUMBING.MECHANICAL CATEGORY CONTROL
/ Anhlled/Engineer. Lac.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ 1:1 1:1LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(mmeame. APPLIANCES-RESIDENTIAL JOB DESCRIPTION
It... Mon to.
the Butlnemand ProlnslonaCode,and my �a
license is in leis tome end effect. PANGS
License Claes LION
Date.Contractor
ARCHITECTS DECLARATION 201-1000 AMPS
OZI understand my plana shall be used as public records. OVER IODO AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O
d����uuuj Licensed Professional SIGNSELECTRICAL '
6
OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC
ZHLrS' Ihereby affirm that l am exempt Learn the Contractors Llrenx Law toe the
po following reason.(Section 76115,Business and Professions Code:Any city or QdEIPR
O Z F• TP.MOR POLE INST.
muntywhldi requbeaa permit tocoretmcy ilter,lmprove,demolbh,orrcpalr
anystm=mpdortoimi once,aisorequimtheappOantforsuchpermitt° POWER DEVICES
- file a signed statement that he is licensed pursuant to the provisions of the
O a: Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi.
0 stoo 3ofthe Bualneuand Prolamines Code)orthat he is exempt therefrom and SWIMMING POOL ELECTRIC VALUATION
6 the basis for the alleged exemption. Any violation of Section 7HIS by any OUTLETSSWITCHI&FIXTURES ` cid x L_)o
gO applicartfar a permiteubjects the applicant to a civil penalty of not rrore than
five hundred dollars($SM. NEW RI IDENTIAL ELECTR
..�n ❑1,as owner of the property,or my employees with wage as their sole SQ.FT. STORIES TYPE CONSTRUCTION
compensation,will do the work,and the structure is not Intended or offend for
Oasle(See7004,Business and Pm(essimu Code:The Comrsam'.Lt..Law
�$ does not apply to an owner of property who Wilde or ireprwn t hereon,and OCC.GROUP RI5.UNITS
who doessuch work himself orthr.ugh Ns own employee,provided that such
Improvements are not Intended oro(fered fwule.If,however,the W ilding or 44 TOTAL:
improvement issad withinoneyearo(completion,theowner-WllderwOl ha e
no(provingthat he did wt Wild o'Impmve(or purpoae.fsale. QTY. P RMIT FEE
ae owner of the properly,am vdusively mntncting with Ilmn FLOOD ZONE APN
project(Sec 7614 Business and Profeskum Cod PERM C
nt . to mmWctthe
The Cmdeaden's License Law don net apply to an owner of property wh .DRAIN (FA)
Wilds or Improves thereon, and who contracts for such p(ojects with a
yt[+sorts)Oared pursuant to the Contractors License Law. FLOW T CE FEE SUMMARY
LJ I am exempt under Sec B Is P C for this reasonllTqlnFFPrq
Owner Data DRAINS I A COND. SANITARY V N_
RECEPT M
•. WORKMAN COMPENSATION DECLARATION FIXT.URF_S SCHOOL TAX Y_ N_
C31 hereby a(lirm that I have a artlBale of consent to xl!•Insu
cerlifiate of Workers'Compersatl.nlnaunna ora atilled
copy theme RECEIPT N
3800,lab C.) CAS EA. -1 IN ,1 OUTLETS PARK FEE Y_ N_
Policy Y
a9RECEIPT E
CmCnGAS EA.SYSITHAVFR 4(EA) BUI LDING DIV
ISION FEES
ertified copy is hereby tumCREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑
Certified ropy is(fled with theecity
ity impaction division. ,
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASBTRAP PAID
COMPENSATION INSURANCE
SEWER-SANITARY-STORM EA 200Ff Datc RCCCI III
RNsxctbn need mat W completed I(thc permit Vfa corm hundred dollars
(g160).r tem.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I cedllythat In the performanm o(the work forwhlch this permit is issued,
I.hall raw employ any person In any manner n as to become subject to the WATFd(SYSTQd/TREATING .
Worker.'Cempensktonlawsof Cahfwnla. Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SOFT. Dale Recei tN
ZO NOTICETOAPPLICt to
orlmofter akingtenCtion prteo(ErempteLyou
HzheuldWmme subject to the Workers'Compereatlon provislona of the labor TOTAL:
cc TA Code,you at feet hwith comply wlthsuch pe,wisiona or this prosel.hall be
deemed revoked. BUILDING FEE 09
CLC CONSTRUCTION LENDING AGENCY SEISMIC FEE a
I herebyalflmnthat there e,a coreruction lending agency for the perform ELECTRIC FEE
ce
D Z onofthew.rkfer which thispermit is band(Sce.3097,Civ.C.) TOTAL:
U O Lender'.Name PLUMBING FEE
LL ~ I.enderaAddm. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U Icertifythatl have read thisappliation and statethatthe above Information
O a Iecorecd.IAgree tocomplywllhall cttyandcounty ordinances and state lam PERMIT ISSUANCE FEES PAID:
>. W relating tobulldingmrutruction,and herebyauthome representatives of this
Z city to enter upon the abovcmentloned property for inspection purposes. ALTERORADDTO MECH. —Date RCCei 1N
V _ (We)agree to save,Indemnify an d keep harmless the City o!Cupertino
against Itabllltlea,jedgaenta,mks and expenses which easy manywayaccrue AIR HANDLING UNIT GO IQODO GEM) SUBTOTAL'
agaire Cityl ens.(the granting dthb pemnll.
AIR HANDLING UNIT(OVER I O,ODO CEM) CONSTRUCTION TAX
u�
Sigr.W/.f Appllant/Contractor - Date FXHAUS'TIIOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future bulldingoavpant.tore or handle hazardous HEATING UNIT(TO 100,00 BTU) Date RLCcI 1N
material as defined by the Cupertino Municipal Code,Chapter 9.1$and the -
Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) AL:
71Yes No
Wllitheapplicant or tune building occupant use equipment ordovices VENDIATION FAN(SINGLE.RGSID) ISS A DATE
which emit hananlou.ui contaminants ae deflned by the Buy Area At, BOILER-COMP OHP OR 100,IXq BTU) DID 1�+a�
Quality Management District? Si
4 Yes No
have read the bazar eusmriedal.requleremate under Chapter 6.95 of BORER-COMP(OVER 100,000 BTU)
the California Ilealth k Safety Code,Sections 25505,25513 and 25534. I
understand that if thebuilding doe,not currently have atenant,that It 1.my NEW RESIDENTIAL MECH. SQ.IT.
responsibility to rally the..pant of the requirements which moat be met
prior to issuance of a Certificate of Occupancy.
Owner or authorized agent Date ISSUED OY: VCJWer`s"r"^s'—"N'
TOTAL:
' OFFICE COPY