23392 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building ng Address: F,\o(-DE C�,77P_� art- 23392
seers ams: Phone APPLICA IION SUBMIITALA
Qw' L40 _ CITY OF CUPERTINO-BUILDING DIVISION ^
Contractor• LIc.N.: APPLICATION I PERMIT (�
SA-t.acE BULDINGELECTRICALPLUMBING-MECHANICAL CATFLORY CONTROL#
Architect/Foglneer. Etc.Na:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: O -FSA {Q- PERMITISSUANCE ❑ ❑ ❑
LICENSED CO
NTRACTOR'S DECLARATION
I hereby affurn that[am Bcensedunder provisions of Chapter 9(commenc APPLIANCES-REME)FNTIAL
JOB DFSOIi[I'1lON
i cense l SeNon7000)af Divbion3mlthe Buainessand ProfesYomCode,and n7 Ra
liana Is In full force,and effect. PANELS
Liner.Clam Lie#
Date Contractor UP TO 2DOAMRS
ARCHITECTS DECLARATION IDI-IWO AMPS
Q'L I understand my phm shall be used as public records. OVER 1000 AMPS SQ.FC.FLOOR AREA S/SQ.FT.
O
�o u Licensed Professional SIGNS ELFLTR[CAL
<D,
� OWNER-BUILDF,R DECLARATION SPECIALCDiCUT/M1SC
L, , I hereby afRrathat l am exempt from the Contractor'.License Law for the
z 0..-" following reason.(Section 7031.5,Business and Professions Code Any city or
O].I.. TEMP.METER OR POLE INST.
F� cwntywhichrequirtsapermittoconstruct,altegimpmve,demolish,ormpair
qqq n mysuture prlarto Its Issuance,also requlrestheapplicent for such permit to POWER DEVICES
.
V file a signed statement that he b licensed pursuant to the provisions of the
On
uContractor's License Law(Chapter9(commencing with Section 7000)of F•wDivi- VALUATION Os slop 3 of the Business and Prefesslom Code)or that he h exempt therefromand SWIMMINGPOOLE.ECTRIC
the basis for the alleged exemption. Any violation of Section 70315 by any!:1OUTLETSSV![TO[iFSFIXTURFS 65 appllcsnt fora permit subjects the applicant to a civil penalty of not more than
c. five hundred dollars(SM.
7< ❑I,as owner of the property,or my employeeswith wages as their sole NEW RESIDENTIAL ELFCIR SQ.FC. STORIES TYPE CONSTRUCTION
compenmtlon,wllldothe wok andthe atocture h rot Intended or offered for
O vie 6cc.701{,Business and Professloro Code:The Contractor's License Taw
$ does not apply to an owner of property who builds or Improves thereon,and
who does such work himself orthrwgh his own employees,provided that such OCC.GROUP RES.UNITS
Improvements am not Intended oroffertd for sale.IL however,thebuilding e T
improvement bsold within oneyearofcompletlon,the owner-bullderwill have
I"neenafprovmgthathadid ni build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE
LJ L as owner of the roe FLOODTDNE APN
property,rty,am exclusively contracting with li Code: PERMIT ISSUANCE
conThe Co onto comicen the w doe(Secof 7W4,apply
Business nom and I&pro ons Code:
The Comramts es then on, does not apply tct an owner d property who ALTER-DRAIN&VENT-WATER MA)
bu11d. or improves thereon, and who contracts ice such Plo/Ms with a
c�7➢jI arose licensed pursuant tothe Contractor'sLlmns<Law. FEESUMMARY
IJ I am exempt under Sec. B &P C /or this reason BACK FLOW PROTECT DEVICE OUTSIDE FI I'S
Owner Date DRAINS.FLOOR,ROOF,AREA,COND. SANITARY Y_ N
RECFLT#
WORKMANCOMPL'NSATIONDECLARATION F�pS PER TRAP SU-IOOL TAX Y N
❑I hereby affirm that I have a ertl0rate of consent to self-Insure,or RECEIPTN#
mnifiateofWorkers'Compensstimlnsuranceoracenifiedcopyth..fLSec.
MOD,lab C.) GAS F.A.SYSTEM-1 INC4OUTLE75 PARK FEE Y N
Palley Y GAS F.A.SYSTEM-0VER{(EA) RECIM 0
Com any B U I L DING DI VI SION FE ES
Certified copy Is hereby ted. CREASE/INDUSML WASTE INTERCEPTOR PLANCHECK FEE
Certified ropy Is filed withh the ted city Wpe tion division.
CERTIFICATE OF E(EMITION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SCWEILSAMTARY-STORM FA.7i)OFF. Date Reoci til
(fhls.etion need sea M complied if the permit b for ane hundred dollars
($1 W)efyil WATER HEATFRW/VRNT/E.ECTR ENERGYFEE Y N_
1cl not that Mt he performanceof thework an as tobthispermit Ishoed,
I smilers employ any person in any runner n u to become objet toted WATER SYSTEM/TREATING Workers Compensation laws of California.Data PAID
C) Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Re i tit
Z O NOTICEca APPLICANT.If,after rs'Co pe Caniflnh is Exemption,Lyon
f" should ode,yo mos objecttotco ply with
Comp rovUonpmvbie permits of Labor TOTAL:
N Code,you most ith comply with such provisions or this permit hall be BUILDING FEE
CL j decrsd rewked. -
consrxucnoN LENDING AGENCY SEISMIC PGE
CL eof the work fo wat hich
ehacomit uction IsEsued(Sce. g ,cy Clo.CJ
heperform- TOTAL: ELECTRIC FEE
� Z anco of the work for whkhthta permit Is Wiled(Sec.309'l,Cl¢CJ
U O ..does Name PLUMBING FEE '
U_ r LendeaAddm,. Q Y. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icenlfythatl have read Nle applkatlonand nate thm thenbove lnfonnstlon
bcorrect.I.greetocomplywithalldtyandcountyordlnance...d Nate laws PERMIT ISSUANCE FEES PAID:
Wrelating to building construction,and hereby authorhe representatives of this
F Z city tocnterupan theabovarasoutned proporty for Inspection purposes. ALTER OR ADD TO MECH. Date Recti tk
V — (We)agree to save,Indemnify an d keep harmless the City of Cupertino F
against liabilities,judgrrent.,coas.nd espense.which may In anywayacooe AIR HANDLING UNIT CIO 10,000 CFM) SUBTOTAL:
gal old City in consaa hb Permit
ryeno/the granting efteit.
Z AIR HANDLING UNIT(OVER IQOOO CFM) CONSTRUCTION TAX
nature of Applient/Contractor to D(HAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA]A RDOUS MATERIALS DISCLOSURE
WE]l the applicant or future building encu pant store or hand le hanrdous HEATING UNIT(10100(.00 BTU) Date RCCei Ili
material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the
He.lth and Safety Code Section 75537((.)7 HEATING UNIT(OVER 1W,IX0]BTU) T
❑ Yes IM No
Will the.pplimt orfuturebuilding occupantuse equipment rdevices VENDLATIONFAN(9INGLERESTD) ISSUaA-N,CUDATE
QM1kh eMt hagenn o t at,trio? Mnanb as defined by the Bay Area Air P
Quality Management District? OOILEWCOMP OFII'DR 100,000 BTU)
Y:, n❑Na - 9 1992
haver la the
calth&rdou modeiabmquirernentsunder Chapter.1 of IIOILGR-COMP(DVIR 1N,000 BTU) MA
the understand
nh at ift e building Safety Code,noNOns ntly h 7e a o ad 75hat it �Y111I�
notporhnity ton tifyteoccupant not a currentlyhavewhich that it Is h'EW RESIDENTIAL MECH. SQ.FT. (;
mpr to Issuance
c of a Ceheacitteof of=pancqulrernenta which most Mmet CITY Ut LL)�E.hl"{U
prior to tssmnce d a Ceni(Icste alOaupanry.
Ownereauthoriredagent Date I UEDBY:_
'TOTAL: —
OFFICE COPY