20897 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project
Identification PERMIT NO.
Bwlamg naareaa:
11-74
2 0 8 9 7
wncrs a e: ` APPLICAFIONSUBMIIIALDALE
W.I u r}Q„_ �t�E6-�L'�'Z.-_ CITYOFCUPERTINO-BUILDING DIVISION- Q� ��p
Contractor's Nam: _ - ueNg: APPLICATION LPERINIT. `�^1�-�'— 10
BUILDING-F3.ECTRICALML BINC-MECHANICAL 9\
Archlteci/Englyder. Lic.Na: CATEGORY CONTROIlSL VI
IQrr' 'ELECTRIC PERMIT i �� ' FEC " "+BUILDING PERMIT INFO
Adtlrcsc ` PERMITISSUANCE ❑ 0 ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that lam llcrnsed underprovisions of Chapters(commrnc APPUANCESRF.SIDENTIAL , JOB DPSCRII'TION
Ing wlth5 cion7000)of Divislon3ofthe Businem.nd Profs,i.n,Cade,andmy
license Is In full force and effect. PANELS
Lkcnad Clam Licp f,\F-[ L
Dao Contractor
ARCHITECTS DECLARATION 201-IODOAMPS
Ob 7I understand my plana shall be used as public records: OVERIMOAMPS. SQ.IL.FLOOR AREA S/SQ.FT.,
z Licensed Professional SIGNS ELECTRICAL
t`n 6 Lfdu OWNER-BUILDER DECLARATION t, -
zi-❑y Ihereby affirm that l am exempt froertbe ContmemeaLl...lawfalhe SPECIALCIRCUIT/MLSC
S following reaser.(5acdon7.18,Busmassand Professions Code:An d or
OZI"Q .n hichm i permit tocorutruct,alter,ion demolbh,Any
TEMP.METER ORIOLE INST.
FE tru qu rea.bags
prove, -
qq < ray stmdvre prlortotIhg he Is lice.sad requires
pursuant to the rovistsuch permit e )OWER DEVICES
file a signed statement that het Boned pursuant to the provision of the
( Ow sun I ofth,urine Law(ChaptersCode)cnMgwliexempn7W0) nean-
3 0� SWIMMING POOL e�.ccrluc !
the basis
for
the
Professions 7031.5byand - VALUATION
the balls!or the alleged exemption. Any vloteHon of Section 7071.5 by any O oO
o' applicant fora permit subjects theappllcanttoa civil penaltyofnot morathan OUTLETSSWITC7dFSFlXq'URFS
rcd dollars(8500). N8W RESIDENTIAL ELPLTR Ff.
1,as owner of the property,ar my employda wfth wages as their sole `"Q' STORIES TYPE CONSTRUCTION
G mP sation,wOldo the work and thestrueture is net Intended or offered for
q ssle(Sc.7044,Buainessand Profession Code:The ContmctoPs License Law
does not apply to an owner of property who builds or Improves thereon,and
EE whodoessuch.,khinaselforthmghhisownemployeesprovldedthatauch OCC.GROUPRIS.UNITS
improvements are not Intended oroffered for sale.IL hcweveq thebulidE g or TOTAL:
Improvementissoldwlthlnoneyearolcomplellogtheowner-bu0derwlllhave _
III: rden of preAng that he did not build or improve for purpose of sale.). dry. PLUMBING PERMIT FEE pLOODZONE APN
u 4 as owner of the property,am exclusively contracting with licensed _ PERMIT ISSUANCEcontmcton to destruct the project(Sec.7044,Business and Profession Code:
The Contractors License Law does not apply to an owner of property who
buALTER-DRAIN&VEM-WATER(EA)
Wilds or Improve,thereon, and who detracts for such pWjad.with a
c actors)licensed pursuant to the Contrad,rb License Law, - , +� ';',,.'.'1 ••'.FEE SUMMARY'
qW� BACK FLOW PROTECT.DEVICE
- - LII am exempt under Sec. B& P C for this mason '
Owner - DRAINS FLOOR{ROOF,AREA,COND. SANITARY Y N
Date RECEIPT 0
WORKMAN COMPENSATION DECLARATION FD(gURES PER TRAP SCHOOLTAX Y N—
❑I hereby affirm that R have a inmra to of aura ifi d pythemof ora RECEIPT K
_�. certificate of Workeri Compenatlonlnaudna gracertifled copynhereof(See GAS FA. INCA OUTLETS PARK FLE Y N
'J 3800,Lab CJ - —
PolicyY _ - RECEOTM
Com ray GAS F.A.SYSTEM-OVER 4(FA) BUILDING DIVISION FEES
�Cand d copy is filedhereby
the cityird. GREASE/INDU9TRL WASTE INTERCEPTOR PLANCI-IECK FEE
❑Certified copy Vllied with the city Wpectlon division. nn �ny [�-
CERTIFICATE OF EXEMPTION FROM WORKERS' ' GREASE TRAP. PAID �J�(�" lC� -31� ^ n
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date ReCel # {SZ
(Thor section need not ed completed Ethic permit is for..hundred tlgllan
(8100)oify th) 1 WATER HEATER W/VENT/ELEcTR ENERGYFEE Y N
Idrtily thailn the performanrc of the work forwhkhnhl,permit i,loved, ,
?,hall not employ any person In any manner m ss to b.mc,abject to the WATER SYSTEb1/TREATING .
W.rkers'CompensaOon Laws of California. Date _ PAID -
C' Z Applicant
Z 0 NOTICE TO APPLICANT.,If, makB.after mixing this Certificate of Exemption,you NEW RESIDENTIAL PLMSQ.FT, Da[ Rec'el 1#
M.
should become subject to the Workdreat
e 'Compelon provig ofthe labor
LU y DTAL:Code,you must forthwith comply Mthsuch pnwisiov or this permit hall be aQT
j drevoked. -
B I N
LU
domed revoked.
CONSTRUCTION LENDING ACE CY SEISMIC FEE s C
I hereby affirm that there h a contructi.e lend ing agency for the perform- TOTAL: ELECTRIC FEE
O ance 01the worklar whlchthis permit Is Issued(Sec.3097,CIv.C.)
V Ia.dd.N.me + - FEE'.' PLUMBING FEE
ly F L nddr'e Adore„ QTY. MECIIANICAL+PER VIII' "," MECHANICAL FEE
O W Icertity that
agreet c mad.ply is with
aliatlonand dcou tyordi aabovedgateaa.n
S redirect.building complywo ,alldcity hereby
author represaand gate laws I'E(MITLSSUANCE" FEES PAID
r} W charelat ng oenobupon to AWve-motioned
penyorI representative.ofthis -
F z citymenteree to ave,Invemily an d prop harm) Impaction purposes. ALTER OR ADD TO MECIi.
(We)apee to save,Indemnify and keep harmless the City of Cupertino Date t
V against liabilities,todgerents,coataand expenses which may In an Way... AIR HANDLING UNIT(TO 10,000 CFM)against said City in consequen fthedrantin !thio permit. f, A R E ANDL NC hTT(OVER IO,X OCFM) CONSTRUCTIOsl namrcor ppuann/egnagmr - ate F_XHAUSTHOOD(W/DUCT, CONSTRUCTIOHAZARDOUS MATERIA CLOSURWill the applicant or future building occupant store orhandle hazardous HEATING UNIT(TO ID0000 BTU) Da[e material as defined by the Cupertino MunicipalCode,Chapter9.12,and the'HrAthand SafdYC Stolon 25532(.)? HEATING UNIT(OVER IW,000 BTU) y+a
❑ Yrs o
Will the applicants future building occupant use equipment ordcA... VFNIILATIONFAN(SINGLERESID) ISSUANCE DATE
which coat hazardous air contamiwnb as dalned by the Bay Area Air
Quality Management District? ' BOILFR.COMP(3TE'DR 1W,IXq BTU) p
4Yes No
havareadtheh a amteroa requlrcmenhunderChapter6.95of BO LFR-COMP(OVER70,UDBTU)
the California Health6 alety Code,Sectims 25505,25533 and 2$534.R QUI+ p [ ���
and drstand that if the building doe,not currently have a tensa nL that It la my NEW RFSIDEN77ALMECH. SQ.1.7 11 M Vy /'I
responsibility to not Ify the..pant of the regquirements which must be {/
Aorto" .Certifi to of Occup,) t,
ati\J \ 11
O�rner or authod int ( / \ / Datrr� ISSUED BY:�J✓
�•1 l TOTAL:
OFFICE COPY