21705 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pr.'ed mentlHvatlon P NIT NO.
�kaeding Addm,,: �7 LO'r- 3`I
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ser, ame: one: AVPLI�HUN hU9.7I`!TA1715A=
CITY OF CUPERTINO-BUILDING DIVISION
tmeto ,Na :
APPLICATION / PERMIT
/ CATEGORY CONTROL N
- U , RH
L No:
n/Cu On C —g BUILDING PERMIT INFO
QTv ELECTRIC PERMIT PEE
Address:
PERMIT ISSUANCE
LICENSED CONTRALTO WS DECLARATION LXJ /K
I hereby
vcsjonaffirm that lam licensedunderBupcesainmof Chaps Code,antr APPHANCESREEDENI'IAL JOB DESCRIPTION
Inlicense I Section 70(10)of d eff an3olthe Bu/sJlnew(and ProfessionsCode,and try
L mnsclCla:RLic.Y PANES
Date Contractor lJ
ARCHITE'CT'S DECLARATION 201-1000AMPS
pZ I understand my plans.h.11 be used as public reavdL OVER1000AMPS SQ.FT.FLOORAREA S/SQ.FT.
CO
`j Llcenwd Professional SIGNSELECTRICAL
OWNER-BUILDER DECLARATION SPECLILCERCUIT/MISC
F, owing raion. tlutlam exempt lromthe Contractor'•Llnn,e law lm the
Z O-5 following reason.f5ectlm 90315,Business and Professions Code:Any city or I J s� 1 '
OZI-� whkhmes TEMP.ME[T7t Oft POLE IN ST. "I "I
FE county cturer toiapermit W amearutruR,.iter,bnpmve,dersuch orrepairmitta
$ ale a signed statement
ihat ncgaice red!pursuant to the fiorsuchat of t e POWER DEVICES
5 01e a signed statement that he t r9(cos pursuant to the provisions of the -
O - Convacto/,Licenselaw Kha erg(commencing with 5ect1on7000)ofDld-
��`os slon3oltheBuainevandPrdealonsCode)or'hrthebexempttherefromand SWIMMING POOL ELECTRIC VALUATION
g u°I 6'St the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS-SWITCHES,FDTURES / (/ 722-
7�� '
E'
applicant for.permit subjects the applicant to a civil penalty of not room than /
c S five hundred dollarsWOO).
pr. NEW RESIDENTIAL.ELECTR SQXT. STORIES TYPECONSMUCTION
c❑1,as owner of the property,or he employees with wage a their dale
compensation,on,will Botha work anssions roctum V not intended or cons eLfor
❑
sale(Sec.7W4,toBusiness
owand f property Cade:The or imp Roes kerion law
$ dm,not apply torn ownerorpropertywho buildsor imprwntMaroRand OCC.GROUP RES UNITS
who does Improvements am
t loundcd orough his own employees,provided ildinghat h
Improvement,sonot Ntenoneorofferedformate.ILh ser-pflder iiI have TOTAL:
improvement iasald withinoneycarofcompletlan,tluowner-0uBderwlll have
m Men of proving that he did.aa wild or improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE
Lj L a,owner of the property,am exclusively contracting with ucc.aed FLOOD 2DNE APN
PERMIT ISSUANCE
contractors to construct the projM(Sec.7064,Business and Profession Code:
The Contractors License law does net apply to an owner of property who ��-DRAIN k VEM-
Wild. or Improves thereon,and who contract, fico such pwicas with a WATER(EA)
C%4.dor(.)licenwd pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE. FEE SUMMARY
Lf I am exempt under Sec. o
B&P C far this mon
DRAINS FLOOR,ROOF,AREA,GOND. SANITARY Y N_
.�
Owner DRAINS. RFLEBTN
WORID.IAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y_ N_
❑I herebyaf(Ian that I have a mrtl0ate of consent to¢I!-insum,ora RFLE['1'N
MOO,lLab C.)ateofiWorkers Compensatianlvurancema<ertl(led copythemof(sec. GAS EA.SYSTEM-1 INCAOUTLEIS PARK FEE Y N
RECE3800,l
Pa • GAS.EA.SYSTEM-0VER!(EU DING DIVISION
Com env )w.r.l4.(1 BUILDING DIVISION FEES
�CZOIrd copytshereq(umldhed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
QCxAlfied copy is filed with the city Inspection divid..
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID �^
COMPENSATION INSURANCE SEWFRSANHARY-STORM EA.200FT. Date Remi tk �J'
O'hls section need na w completed I(the permit V(or one hundred dollars
(5100)o - WATER HEAT W/VENT/E.ECTR ENERGY FEE Y N
Imrtifyilythat In the performance oHhewmkfar which this permllb blued, —
1 shall not employ any person In any runner so as to become subject to the WATER SYSTEM/TREATING
Workers Compensation laws of California. Date PAID
O Z Applicant NEWRESIDENTIALI'LMB. SQ.FT. Date Rea:( tH
Z O WTICETO MPLICAM:H,after making
omthis
enCeronlprovis Exemptie LdW
shoed become subject to the Workers'Compensation provisions of the Lawr TOTAL:
� y Creenedr =at forthwith comply with such provlsbnsorthl,permit shall be BUILDING FEE
deeaN revoked.
W > CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL O I hembyalRrmthat there is a mnsuudion lending agency for the perform ELECTRIC FEE
D Z ance olthe work for which thbprml V it(Sec.3097,CIv.C.) TOTAL:
U O Icndero Name / _ PLUMBING FEE
LL ~ Leader.Adare,. QTY. MECHANICAL PERMIT FEE MECHANICALFEE
O W Icertlfythaelhavereadthiaap iatlon and niaethat theabove lnFrr don
Ise logt building
uilds gcomplywlt arII city andhereb authoounty ce,repress ati date thisaws PERMIT ISSUANCE FEES PAID}
} N
city to
enterupongcomtmctlogaMhembyrtyorin mpmentalvn of this --f�-r/[D//aT/-11-1Q-1,- OkNT�—
Z cityWenteree to save,
eawvemnify and property for inspection of purposes. AL77AOR ADD TO MECH. ate RCCCI [11
— (id)agree to pod, Indemnity and keep harmless which the City o/Cupertino P
age Wt liabsaid itynaxesxi;coe of the
<xpensn which pmay to ermit. wayaaxue AIR HA NTENC I1NiC(TO 10,000 CEM) SUBTOTAL:
against said City in/co�4nsequen¢oftM gra ntingdthis permit, MR HA NDUNG UNIT(OVER 10,000 CIM) CONSTRUCTION TAX
Signature of App ill/I�i Conictar� / Date EXHAUST HOOD(W/DUCT) C20 STIR C170NTAXX PAID:
HAlARDOUS MATERIAL ISCLOSURE Will the applicant or future building ccs ant store or handle havrdous HEATING UNIT(TO 100,0DO BTU) Date RCCCI IM
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
liealth and Safety Cade Section 25532(.)7 HEATING UNIT(OVER 100,1X10 BTI) TOTAL-
❑Ye, M No
Will the applicant or future wilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit harardous air contaminants as defined by the Bay Area Air
. Qu Pity Management District? BOILER-COMP pFIP DR 100,000 BTI) �p0�
Yn Na ami
4)uvcmadtheh❑
sous mate ab ry ire ents under Chapter G95 of BO LER-CUMP(OVE 100,000B )
the California Health&Safety Code,Sections 25505,2.5533 and 25534. 1 FEB 141991
understand that that ifthe building docs not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.Ff
responsibility to notify the occupant of the requirements which must be met
priortolssuance aCertific,te.f mpancy. I!� Aran
Owner or i.thcLf7,dagent Date ISSUEDBY: L
OTAL:
OFFICE COPY