S 0718 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-E.ELTRICAI, PI* ITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J 0718
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMI'ITAI,DATI
p 52-5 v JA-e-97
O ER:S N ME PHONE: CONT CTOR:S NAM / LIC N
s `� NIC RULp CONt'
It,
ARCO]ITC EFNGINEER: LIC NO: ADDRESS: ❑
OV
CONTACT. I'IONE; - BUILDING PERMITINFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
r t u.� 3 06 18 ❑ ❑ 0�❑
LICENSED CONTRACTOR'S 'CLARATION QTY. ELECTRIC PERMIT FEE
1 hereby of nathin I am licensed ander provis ons of Chapter 9 u„mmen in, JOB DESCRIPTION
OCZO with Seminn](XV)of Division 3nfthc Business and Professions Code,andmyncense is RESIDENTIAL;
ttyy�1 PERMIT ISSUANCH.
Fa,- in full foreeand effect. ❑SFDWL ❑KIT 1{PN IPMODEL
�UU License Class LieM APPLIANCES-RESIDENTIAL ❑AIIIIITION LHMBING RIi-PIPE
F w Immo Com.ou
m o. ❑MULTIUNIT ❑STRUCTURAI.
ARCHIT'ECT'S DECLARATION
p„p lin UPTOPANELS MODIFICATION
Z O'�'? 1 understand my pins.shall Fe used az public,cords
O�'(,)Q UP TU 21p AMPS ❑INTERIOR ❑CHIMNEY RIiPAIR
Licensed Professional 201-IMM1AMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUH.DFR DECLARA'1'I ON
OVER IPOP AMPS 01 THE RIiM(IDh;Uklel'Alk I]IiMOLITION
W Q 1 masa .Rem that 1 1. exempt from the Cessions o e:Any
Law I(t,the
iq5 6 U which re reason.ecruit t ]NLS.Business and Professions Code:Any city or county SIGNS IA.ECIRICAI. OTHER
sN W O f•- which rvquiros a permit m cnnsuucl,silo,improve,demolish,t file
repair any alta cal
ure
pnotion,Issuance,also retreats lM.pplicam ta,ach permit to Elc uslgned s«namem SPECIAL CIRCUI'I'IM15C.
Ythat he is licensed pursuant,.the residues of the Elemental a License Law(Chapter 9
fy pG�p lermerati g wide Section 7”)of llivlsion 3(tribe Business and Professions Cade)or TEMP.METIER OR POLE INSII COMMERCIAL:
Inst he is cxcmpl trachoma and the basis for the alleged cxemp,inn.Any violation.f a ❑NEW BLDG/ADDITION ❑DEMOLITION
tion 9031.5 by any uppllcanl normi
a pert.subjeeb m n the applicant cervi l pen�ltyof POWER DEVICES
Sec ❑Tt:NANT FOOD SERVICE
tae Than five handed dollars(8500). IMPROVENMlir
�ZC ❑I,us owner of dee pmpeny or mycmployeeswi,h xmgen as their solecompensntion, SWIMMING POOL ELECTRIC
will ihi me wok,and the s0uentre is cot intended or offe ca for sale(Sec.9041,Business ❑OTHER
W and Professions Code.The Cotnmcmrs License Law docs not apply a an owner of OUTLETS-SWITCHES-FIXTURES
CC property who builds or improves Thereon,and who does such work bi inself or through
his own employees,presided that such improvemetns am a.,intended or offered for NEW RESIDENTIAL 11ECTR ;(EA)
sale.If,however,the building Sr i enprevemene is sold within one year nlcnmpinion,the S FT.FLOOR AREA SISQ.FT.
inner bolder will have The harden of proving thin he did not huild or Improve for par- ��7� >�
pose of sale.). Y v
I]I,as owner of the properly,am exclusively contracting Isith licensed contractors to L:
construct the peeler,(Sec.AMM.Hnniness and Pmressinns Cale:)The Contractors Li- DEC
pS O lis
cense oDow ants nmapply oloant in a of loosely ince sedpuw6opnwific Co.m,und QTY. PLUMBING PERMIFEE Gl' 8 1997
who contracts for such pngeces with a nmwmoHs)IlecnxcJ pursuunT w the Comnnnor's
License Low,' PERMIT ISSUANCE
1 me exempt under Sec. B&PC for this reason BY.•
ALTER-DRAIN&VENT-WATER
Owner Dom
WORKER'S COMPENSATION DECLARATION BACK MOW PROTECT.DEVICE -
I hereby affirm.Mer Penalty of of
.rte of the insumfollowingr declarations::
❑Ihnvc and will foi by Section 37ne of the Lotto sel Code,
for the Workersceof the DRAINS-FLOOR,ROOF,AREA,CONDI STUI<IF.S 'I'VPF.CONSTRUCTIOI
.mann,as provided far by$emimt 3llq of the Lothar Gude,Ibr the 1¢rinrtnance nl the ,
work far which this pcman is issued. 1X9VRIS-PER'1'RAP O
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 or The Labor Code.for the performance offle work for which This percent is issued. GAS-FA.SYSTEM-I INC.J OUTLETS OCC,GROUP AIN
My Workers Compensation Insomnce carie,and Policy:ember an::
Cartier: Policy No.: GAS-PA.SYSTEM.OVER J(1IA)
CERTIFICATE OF EXEMPTION FROM WORKERS' 11
GREASI%INDUSTRI,WASTIi INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not be completed it the Perth is l"or one hand,.]doll...1 SI(X)) GREASE TRAP
or less,)(This
THE
I amifyunl in the performance of the work for which thispernil is issued,l shall SEWER-SANITARY-STORM EA.2(10 IT.
net employ nny person many manner so as a m
becoe sua bject Ih.Workers'Comr,
fieENERGY FEE
0Z satins Laws of California.Dale WATER HEATER WNENT/ELCCTR GRADING FEE
Z O Applicant e
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should WATER SYS7EMIG'REATING
a
Internal,subject to the Worker's Compensation previsions of the LUMn Code,you must SOILS FEE
forlhwith comply all such provisions or This pennh shall be deemed revoked. WAT17H SERVICE
0 2
CONSem is.c0NLENDINGAGENCY NEW RESIDENTIAL PLMI{. SQ,FT. PAID J
LJ k raluch this
peraidi ls.conmrec-10leading agency for the perf.nnnnco of Dam Reccipe
f~' the work fa which thio permit is issued(Sec.31sT,Cie C.)
Q U LechOl Name O L.
LLI Lenders Address TOTAL: . e
1 eerily that I have read this cppliemion and state That the above Inrmnmtion is BUILDING 19Ti
i..e Yq erect.lugreeeo comply with nil oily and county ordimmccs and store lnwxrclmingtn QT'Y. MECHANICAL PERM IT FEE
U Z building construction,and hereby.Ideon.representatives ofthis city to enter upcnthe SIiISMIC PFh
abave•menei.eed propcny for inspection purposes. PERMIT ISSUANCE:.
(We)agte m save,indemnify and keep harmless the City of Cupertino against ELIiCD21C FEE
liabilities,judgments,costs and expenses which may In any way accrue against said City A 1.117I10R ADD'10 MEC I1. PLUMBING THE
G
in...sequcne t of the granting of thi,permit.
APPLICANT ORDERS ANDS AN TL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,(XM)CPM)
A1IiCHANICAI.FEE
SOURCE RE .AT .5. �s
^vr AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUGHON TAX
Signamr Ap mt/Curaccenr Dae EXHAUST HOOD IW/DUCT) HOUSING MITIGATION FEE -
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant see or handle heszanlpu,cnn.i.1 HHA'd'INC,ONI"f(TO 1011.010 BTU)
as defined by the Cupertino Municipal Calc.Chapter 9.12, name Ileal.....Safety
Code,Section 25532IaD HEATING UNIT(OVER ISS MIB BTU)
E]Yea, Fl No VEND LATION PAN(SINGLE REME) PAID
Untc ReceiptM
Will she applicant or future building trcupum use equipment or device,which
emit hvallons air conformance,as defined by the Bay Area Air Quality Manm
ageent B011.lik-COh11'(3NP OR IIp,g10 BTU) tt)TAL
WA
Disesn!
El Yes ONo BOILER-COMP(OVER❑MI,IXNI BTU)
AIR CONDITIONER
I have ,S the hamNnm tion2materials requiemcros under Chapter understand
d t the Cali- - ISSUANCE DATE
lain. Health&Safety CMT,.actino25505,is no,and255Yf.I understand that Ifthe NEW RESIDF.MI'IAI.MECII. SQ.FT. Oy 9
building aces nm ear.ntly hay.n enIn r Ihut it is ua resloaxibility m notify the(tccup.nt
of the nyviemenls which tun he con prinnn issuance afu Cenifcam of Occupancy. '
Owners mahmimdagece Date TOTAL: ISSUED BY:J.fJ ` en
OFFICE