24018 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PERMIT NQ, 4 018
Building Address:
APPLICATION PC-
%,�anlC she/tins Z 5z- 888 SUBMITTAL
CITY OF CUPERTINO-BUILDING DIVISION
CoatratleraName2 J LI7=.NCef APPLICATION / PERMIT5-06 '
Marto V 7 BU LDINGaECTRICALPLUMRINGMFLHAMCAL CATEGORY CONTROL N
• Architect/Engineer. Lac.No:
ELECTR[CPERMIT• ,;, ;� , ,PBC,�;�� '' BUILDING PERMIT-INF,O,,,.• 6,
Address: PERMITISSUANCE El El 1:1LICENSED CONTRACTOR'S DECLARATION
Ihereby aff 7000atlamll=ensedh"Bur I rovblonsafChapterm1,.nd nc- Al'PI-IANCE4RE.4DENTIAl JOR DESCRB'TION
In ease i Section 7oma and dieon3ofthe Buelneasand Professions Code,and my
license Is in lull force end tcN , PANELS ,
LlcenseCa® 7-/.7G�LItN ' Ila
Date ry� / Contactor�e� sonnyUP TO 20D AMS
1�77 ARCHITECPS DECLARATION 201-1000 AMPS
q�2C. Iundentandmyplaroshallbeueedaspublicrerorda. OVFR10DUAMPS - SQ.Ff.FLOOR ARFA $/SQ.FT.
C� D I N
k O U Licensed Prof esionzl - - SIGNS ELECTRICAL
<«<� OWNEReBUILDER DECLARATION SPECIALCIRCUTT/MISC NIT
owing yavermthatlam81.5,Bsimasaxempt froon Cntrfrisioshade;Lawcombs following reason.(Section 7611.5,Businemand Profemlons Code:Any dty or
Kucmntywhichmqulresapermitiommtmctalter,bnpmve,demolish,orrepalrTFNP.METERORI'OLE INS .� anysuucture prlorto Its Ismancealse requlrestheappllcant forsuch permit topOWpR DEVICES '
Oilk a signed statement that he Is Banged pursuant to the provisions of the LL D
������{{{{{{ Contractor's Lleense Law(Chapter with Section 7000)of Dlvl- SWIMMING POOL FT ELTRIC
90 sion3 ofthe Business and ProfesalorsCode)orthat he is exempt therclromend VALUATION
S" the Turtle for the alleged exemption. Any violation of Section 76i1S by any I 1 DO o QO
O4 applicant for alleged
exemption.
Any
vioation penaltyn nM morel hay OUTLETSSWITCHCSH%7URE5 11
$ five hundred dollars(¢500). NEW RESIDENTIAL ELECTR 7Y1'E CONSTItUC'IION .
I,as owner of the property, ��' SI'ORIFB-
Z p party,or my employees with wages r the sok
k p h compensation,Business and k.fiesim sC de:Th Contot ractors
or offercense L w
or
SFO sale(See 7644 Business and Proleselors Code:The Contrasots Liceme Law
�,i j$ does not apply to an owner of property who buildscrlmpreves themon,and OCC.GROUP RFS.KNITS -
WW who doessuch work himself or through his own employees,provided that such
Improveoxra..nm intorded oroffered for sale.If,however,thebulldleg or
Improverevelosoldwithle oneyearafmmplMiomtheowner-buRderwlli have TOTAL:
the burden of proving that he did not build orimprove forpurpose mule.). QTY, * k PLUMBINGPERMIT ',FEE Flppp ZONE APN
u[as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
centractots to construct the project(Sec.7644 Business and Professions Code:
The Contractors License Law does out apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or improves thereon, and who contracts for such p[u)ess with a
[!It
licensed pursuant to the Contractors License Law. t � U
FEE'SMMARY
cut am exempt under See. B k P C for this reason BAIX FLOW PROTECT.DEVICE nIlYqIDE
DRAINS FLOOR ROOF,AREA,COND. SANITARY V N_
LN
Owner DateK
.• WORMAN COMPENSATIONRFCFRTN DECLARATION FIXIURF_S.PER TRAP SCI;OOLTAX Y_ N
❑1 hereby affirm that 1 have o artificateuranc of consent to opythaurc,ora RECEIPT N
adlflcab of Worken'C"mpeweon Insurance ora rertlfkd ropythemof(Sec. GAS EA.SYSTEM-11NC.40U7LLT5
3800,Lab C.) PARK FEE Y_ N_
I'MIryN _ GASEA.SYSTEM- - RECEIPTN
Company OVER4(EA) BUILDING DIVISION FEES
oCedl ed copy is herebythe city
d.
GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�Ebrtified ropy k flied withh the tlty Ivpectlon division.
CERTIFICATE OF E a(EMPf10N FROM WORKERS' GREASE TRAP - PAID .
Cot Wcom
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date Remi t#
(1),ulesion need not be complsed If the permit V for one hundred dollars
(51 W)rtifyt3 nd WATER HEATER W/VENT/ELECTR ENERGY FEE Y N—
I
that In any person
In any m neerwork fortowhich co permit ed to the
I shall not employ any,La.In any manner ea v to become mbJect to the WATER SYSTEM/TREATING
wurkers'enmpeneainn Law.or caurnmw. Date PAID
Q Z Applicant
Z O NOTICE TO APPLICANT.lf,aftel nuking this Certlficateof Exemption,you NEW RESIDENTIAL PLMB. SQk . Date Retel t#
should become eub}xt to the Workem'Comperuation provisions of the Labor TOTA
CCtil Code,you must fodhwith comply with each provlalorsarthis parmlbhallbe FL•E �'�
> deemed revoked. BU 4DING
CLG CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency for the perform-
7 O ance of the work for which this permit is Issued(Sec.3097,Civ.C.) TOTAL; ELECTRIC FEE
V Lmder's NameqPLUMBING FEE
Iy 1— acre nddreea rY. `• MECHANICAL PERMIT , FEE ' MECHANICALFEE
O W Iced ify that l have read l Maapplicadon.M state that the above Information
1 lacerrcs.I agree tocomply with all city and county ordinances and elate laws PEWITLSSUANCE FEES PAID:
W relating to building constmctlon,and herebyauthmize repersbntativeso(this -
Z city to enter upon the above-mentioned property for Inspection purposes, ALTFRORADDTOMECIL
(We)agree to save,indemnify an d keep harm de,the City of Cupedlno Date Reeei t#
V against lkbilltio,Judgments,codeand exp r.,ivhich may lnanywayaccus AIR HANDLING UNIT(DO 10.ODDCFM) SUBTOTAL:
aR at.tsald Ci In eamoft tin8 ofthle mut.
ATR HANDLING UNIT(OVER 10,MOCFM) CONSTRUCTION TAX
"
Signature of Appica"t/Comracto l� / Date I EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,OW BTU) Date ReCei t#
material as defined by the Cupertino Municipal Code,Chapter 9.1$and the - F
Flealth and Safety Coda Section 255320)7 HEATING UNIT(OVER 100,000 B'I'U) ' TOT
nn Yes No
�FNlilthe Spplicam or tuturc building occupant use equ 1pmem or it avices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE'
which emit baa relous air cents end narts as deo ned by t he Bay Area Air A 1 Quality Management District? BOILER-COMP OHP OR 100,000 BTU) "
4Yes ❑❑No
havc read the haallous materials regWmmentsundto hapter6.95 of BOrLEILCOMP(OVER 100,000 BTU) 'JUL 2T) 1992
the Callfernia Health k Safety Code,Sections 25505,25533 and 25534.I JV (J OO l�
understand that if the building does not currently have a tenant,that it is my NEW REMDENTIAL MECH. SQ.FT.
rm /���
pmeebility to notify the occupant of the requirements which must be met
- CITY Uf Cl1F'r=YYI IIY'--
prior to issuance of.Cedificato of Occupancy.
Owner or authorized agent - Data _
ISSUEDBY. "/
OTAL:
OFFICE COPY