24134 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification - Pl9ihllTN24134 "413 4
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CITYOFCUPERTIN4 U INC DIVISION I�oj n
Cono-gFt.r's hr.me: ^ Lm.N. APPLICATI / PERMIT Sass,
BUILDING-dL]'LOMBINC-MECIIAMCAL CATEGORY CONTROL#
' Archaea/Engineen Lic.No:
'QTY "�' ECTRI6.PER BUILDING PERMIT INFO '
Add.. ,T ISSUANCE _❑ 11LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provblonso(Chapter (co c- APPLIANCEAW.SIDPIZAL JOB OFSCRRTlON -
Ingwithsealon7000)of Division 3 ofthe Business and ProtnalonsCo ,
license Is In full force and effect y PANELS
License Cissa Llc.N
Date Contractor ARCHITECTS DECLARATION 201
.1000 AMTS
ONQ I understand my plans shall be used aspublicrecomds. OVER 1000 PS - SQIR.FLOOR AREA S/SQ.FT.
r�rG��E Licensed Professional SIGNSEL CAL
a6toOWNER-BUILDER DECLARATION
I'n SPECIALCIRCUIT/MISC
7p, owing rasormthatlam.xc.pt from 31.5,Bsinessthe Contractor's s Code:Gy city he or
pp countyw reason,terga n7031$B..Itruc and Processions Code:Any sty or �.
OZti� can which Iresa permit mown,alter,im TEMP.MLTfR OR POLE INST: '
�� county requ pe pose,demolish, repair
g(�ot any at ructure prior to its Issuance)a lar,requires the applicant for such permit o POWER DEVICES
file a signed statement that he Is licensed pursuant to the provisions of the
3pfn Contractor's License Law(Chapter 9(commlencing with Seaton 7000)of Diel- SWIMMING POOL ELECTRIC
sion3ofthe Buelneseand Profemimu Code)orthathebemm ihere(romand VALUATION
Q the bash far the alleged exemption. Any violation of Seaton 7031.5 by any OUTLETSSWITCHIM-FIXTURES
�+
applicant fora permit subjects the applicant to a civil penalty of not more than
$ five hundred dollars(SM.
I,as owner of the property, NEW RESIDENTIAL ELECTR_SQFT. STORIES TYPECONSTRIICTIOR
j.. ❑ p poky,or my employees with wages as there sok
C com(Sec.744,wllldothework,and th.Code:Th Corurot endedo?cense Law
'S offered for
Osale(Sec. pply ffito anives meandf property
Code:The or
rImprves theme,and does not applyto an owner.(property who builds orimprwesthereoRandOCC.GROUP RFS UNITS
who does such work himself or through his own employees,provided that such
improvements am not Intended orotfered forsale.I(,however,thebuilding or
improvementusoldwithlnoneyearofcompletion,theo ner-bulWerwlllhave '
I enofpmvingthat he did not build or Improve(urpurposeofsals.). QTY, PLUMBING'PERMIT" r FEE-, FLOOD ZONE APN
as owner of the property,am exclusively contracting with licensed ppggRT ISSUANCE
-' to ore to mnatruct the project(Sec.7044,Business and Professions Code:
e Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilda or Improves thereon,and who contracts for such p(ojeas with a
gA,1RTaaor(s)Ilmnaed pursuant to the Comeaaorb License Law. FEE SUMMARY
IJ I am exe� under See. B&P C for fhb aeon BACKFLOW PROTECT.DEVICE _
DRAINS FLOOR ROOF,ARRA,COD. SANITARY Y N� -
Owncr Date REC
pya(gT/gpR,PER TRAP SCIi00l TAX RD EIPT N
N_
WORKM CO P SATION CLARAT N
'
01 hereby affirm that I have a certificate of consent to seimmune,ora kit
reRECEIPT N
S late ofWorker%Compereatlon lrsuranreora rekl(led copythercof(Sec. GAEA.SYSTEM-1 INCA OUTLETS' PARK FER Y N
hif
Policy N GAS-FA.SYS'T'EM-OVER 4 MEA) RECEIPT N
Cam any BUILDING DIVISION FEE
�Cekified copy is hereby furnished. GREASR/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
MCertlfled copy is filed with the city Impaction division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE ShWFR-SANITARY-STORM RA.200FI'. Date Reeei 1#
Trhb section need not be completed lithe permit Isforone hundred dollar
($IM)orless.I ..ATE&IIEArQ4 w/vENr/ELCCTR - ENERGYFEE Y N
ce
I rtify that in the performance o(the work for which this permit is Issued,
I shall not employ any person In any manner an as to bemme subject to the WATER SYSTPM/TREATING.
Workers'Compenastion laws of California.Date PAID '
C' Z Applicant - NEW RMDFNTIAL PLMB. SQ.FT. Date Recei t#
Z O NOTICE TO APPLICANT.If,after making this Cnnifiate of Exemption,you
should become subject to the WorkerCompenaztion provMom of the Labor TOTAL:
CC W Code,you mu at forthwith comply with such provisions or this permit shall be BUILDING FEE
W > deemed mvoked.
IZ C CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a mrutruaion lending agency for the perform- ELECTRIC
Is FE
7 Z ance ofthe work for which this permit iscued(See.3097,Civ.C.) TOTAL: 1r,
(�•O Lender's NameP L,
LL f Tender's Address 0Y., ' _'MECHANICAL PERMIT' ''PEE.',, CF NI -AL
OO Icertilythatl have read thbappilatiooand stalethat the above ln(ornutimn
ais rrect.Iagreeto comply with all city and county ordinances and state laws PERMTTISSUANCE F P! ID:
} relating to building comtrecion,and hereby authorize......n.......of this
F 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 Date Receipt#
V against llabllities,judgments,mks and expenses which may in any way accrue AIR HA NDLING EMT(1'010,000 CFM) SUBTOTAL:
agxbstaald Cuyi censequenceofthe gr ingofthhp.rnit.
n A)RHANDL]NGUNr(0VFRI0000Cr•M) CONSTRU ON TAX
sl of AppBant/ on mason
Ush F7(HAus r HooD(W/DUC1) CONSTRUCTI TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant o,hourc building cuompatomme or handle hazard... HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Cods,Chapter 9AZ and the Date eaei N
I Tealth and Safety Code Seaton 2SS32(a)? - HEATING UNIT(OVER 100,000 BTU) ,
Yes No
Will the applicant or future building occupant use equipment or devices VENIILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit lut.ed....fir met mirtants as defined by the Bay Area Air n
Quality Management District? BOILER-COMPOHPOR100,"RI'M 1
4Yes ❑No
havereadthehHrahhdcSafcAyCodriabrons255nbundeaChapter6.95of . BOLR-COMP(OVER 100,000BN)
the understand
t at Ifth& Skiing Code,Sections25505,25533have
a tend,that I] AUG 2 4 1992
understand that if the building does not currently have atenanl,that itIsmy - NEW RESIDENTIAL MECIi. rQ.FT
responsibility to notify the ocmp.nt of the requirements which at be met _
prior to Wua nee of a Certificate of Occupa ney. C1IV .
• VrCw
Owner or authorimd agent Date
TOTAL: ISSUED BY:
OFFICE COPY