24084 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building project Identification PERMIT N94 4 084
Building Addms: o.
16
arc: Fluxes:
per. CITY OF CUPERTINO-BUILDINGD
o lractor'eNa 'Lic.Nq: APPLICATIONl j FgR �Q
DGL cw�.7 'vcT/O^/ S BUILDING-ELEC RCA PL , G-MFLHAMCAL CATEGORY C
Architect/Englneer.5-/O�y2�p- 006 Lk.No: BUILDING PERMIT INFO
TY RICPERMIT^ FEE
Address: TISSUANCE
LICENSED CONTRACTOR'S DECLARATION
thereby
affirm that l am licensed under provWons of Chapter9(ememenc-I I APPLIANCFS-RESI BDFSC ION
ingwlth5ection 7000)of DlWNon3 ofthnguelmsand Prolnelona Code,and my
license hiin fullforce and effect. P
License Chs LIC# .a
Date Connector
ARCHITECT'S DECLARATION A I-1000 AM ns
I understand my plans shall be used as public records. LRI000 I �� SQ.FT.FLOOR AREA S/SQ.FT,
00'LO C0 Licensed Professional CNSE CAL O DO 2G
«< ku OWNER-BNLDER DECLARATION SPECIA CIRCLE ISG '��a
ZF UUUU� Iherebyafll.thail...xemptfrom the Contractor's License Law lorlhe _
O following reason. 70315,Business and Profesince Code:Any ctty or
K "8 emnlywhichrequlresaper tmcomtm"tegfmpmvedemollsh,ormpair TFMP.MC OR POLE INST.
AM �a anystructure prlorno its issuance,also requlreanhe applicant for each Parnell to POWER DEVICES
K U file a signed statement that he is licensed pursuant to the provisions of the
O n Contncmr's License law IC Fxer9(commencing with Section 7[000 of Divi-
�OS sion3ofthe Businesand Pro(esiona Cod0orthat heisexempttherefmman SWBdMING1WLELECTRIC VALUATION
the Want for the alleged exemption Any violation of Semon Illi LS by an a� �y I
five handredapermitsub)ectsthe appilcjnttoadvll pemlty of na[mure lha 7 �T'El' TCFIGSFI)"CURES +Q
qqq flue I,asoddo of ars
00). l C q SQ17, S�pRIES TYPECONSIRUCTION
'9Z.-'
MI,ee owner l the property,or m#eml{pyreeA with snag�s�ir M' L ELECTS
5a< compewtlon,wBldothe work andlFePtru relsrwt lnlendM or dlfek fol
5 C O axle(Sec.7054 Business and Pm(esbtu Cad TM Conlracloti l5etuc I�pw'
[ $$ docs not opply to an owner of property who ilde or improve ereal4 d _ OCC.GROUP RIS.UNITS
whodoceeuchworkhlmedforthroughhhow, ploye77 ids t tcfr
Improvemenlcare not intended oro(fere fossale.If,howeveq the�W�ipW'�
i provementUwld wlMinoneyearofc p1elo buildlrwil a� - 1
ti�kurden otpmving Mat he did not Id orlm�o Qiy, P 1NC PERMIT 'FEE FLOOD ZONE APN
L1 L as owner o(the property,am Ively contracting with licensed p�PPISSUANCE
contractors to construct the project(Sec.7044.Business and Professions Code:
The Contracto's License Law does not apply to an owner of properly who ALTER-DRAIN kVENT-WATER(EA)
builds or Improves,thereon, and who contracts for such p(njectn with a
cg0tfactor(s)licensed pursuant to the Commences License Law. BAIX FLOWPROT .DEVICE FEE SUMMARY
1_f I am exempt under See B k P C for this reason
U DRAINSF100 ND. SANITARY Y_ N_
OUTSIDE FEES
Owner Date RECEIPT#
WOKRMAN COMPENSATION DECLARATION FIXTURES PER ��� SCHOOL TAX Y_ N_
01 hereby affirm that f have o )mummetificate of consent to lel(-Inwrc,or a RECEIT'#
3800,Laftifiab ofWorkers'Compenaanlonlnauranceoracertified mpythereof(Sec, GAS EA.SYSITM-1 INCA OUTLETS PARK FEE Y N
3oA,lab CJ
Policy p CAS EA.SYSTEM-OVER d(EA) DING DI N
Co soy BUILDING DIVISION Fr.ES
r'Certified copy is hereby tume city CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK
r7 Certified ropy Is filed with the my Inspection divblon. r•iyr�
CERTIFICATE OF EXEM PTION FROM WORK ERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANI.f.ARY-STORM EA 200FI' Date Recc I
(This settlors need not be completed If the permit ls for one hundred dollars
(5100)orfy th WATER HEATER W/VENT/ELFCTR ENERGYFEE Y N
1 cent that o the person in anof y
he workmimner so as to b this permit I.c Issued,
I shall not employ any person in any manner m s to become subject to the WATER SYSTEM/TREATING
Wormpensllon Gsv.o(Cali(ornh.Date PAID
Applicant
NOTICE O Z OTICnt NEW RESIDENTIAL PLMB._SQFT. Date R 1
Z O NE TO MPLICANT:I,after making lhls Certificate of Exemption,you ,w••'
N should become subject to the Workers'Compensation provlalom of the Labor �"[ oofi ^a -TO
Code,you trust forthwith comply with such pmvlsiona or this pemdt.hall be "'[J V+ �eNA • BUILDING
deemedrevoked. FEE
W CONSTRUCTION LENDING AGENCY SEISMIC FEE _
a Ihcrcbyaftfrmthit there Is.comuructlon lendingagcnry forthe perform- ELECTRIC FEE
O ance ofthe workfor which this permit is isied(Sec.3097,CIV.Q T
(.) Lender'.Name �- Ir
LL 1= Looderb Address QTY. MECHANICAL PERMIT FEE M G ate'•
OW Icedlfythat l have read this appllcaHonand statethet theabove Information
IL is correct.Iagreelo comply with all city and county ordinances and spate laws PERMITISSUANCE � � FEES PAID:
>. N relating to building construction,and herebyauthodee representatives o(this �_
F Z ctyno enterupon the above-mentioned property for Impection Purposes. LTERORADDTOMECFL Date Recei tN
(.I _ (We)agree to save,Indemrdly an d keep harmless the City of Cupedinu P
against liabilities,judgmente,massed expenses which may in anywayaccrus AIR HANDLING UNIT TIO 10,000CPM) SUBTOTAL:
against said City In consequence of the granting of this permit.
aRldnraouNCUNIT(OVER lo,aaCFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST HOOD M/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wllltheappheant or future building ocmpantstore or handle havardous HEATING UNIT(TO 100,000 BTU)
rraterlalasdeBned by(he Cupertino Municipal Code,Chapter 9.12,and the Date Recei
Healthand Safety Code Sectlon25532(a)7 HEATING UNIT(OVER 100,O00 BTU) TO t
❑ Yea k,No
Will the a pplirant orfuture building occupant use equi ptnenn or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havrdous air contaminants as defined by tM Bay Area Air p p I N�
Quality ManagementLltdctt BOILER-COMPQHPORI00,IXDBTU)) N' A Y
4 Yes 6,No
have read the hazarr Juinatarlab ulreme under Chap ter6.95 of BOILER-COMP(OVER 100,000 BTU) SEP 22 1992
the California health&Safety ode, one 2550 3 and 25534. 1
understand that if the bufldl due co nil a atenant.t titlsmy NEW RESIDENTIAL MECH. SQFT.
res t Ilftymnal I P fth lawhieh stb
pito uance of ca/e an v sem• CI I Y OF CUHCTi I IIYV
or authorial
uthor) ge Da ISSUED BY:
OFFICE COPY