22558 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification PERMITNO.
Building Address:
7 (,5 o�.i✓6D�c Cvobe,,77nle I . 22558
eters %K� /�fLSO� one CITY OF CUPERTINO-BUILDING DIVISION (C�72 �.
�AjCo odor N me: ace. o: APPLICATION / PERMIT - J 4�1
/Q��•rlr/s�• 319No� BUIIAINGELECTRICALMUMBINGMECIiAMCAL CATEGORY CONTROL N
Arc ted Engin¢r. 41c.Na:
C G• BUILDING PERMIT INFO
,Q?Y ELECTRIC,PERMIT 'FEE
Address: S4 gC4. -J.3 PQthRTI55IlANCE Pecl
LICENSED CONTRACTOR'S DECLARATION El El El
I hereby affirm that l am licensed under provisions of Chapter9(mmmenc. APPLIANCES-RESIDENTIAL JOB DFSCRRsITON
ingwith 70000of Dlvlelon3o(the Buslnseeand ProfewloneCode,and my
limns bin full fo aid dfN PANELS
Llmnec C�"/„". CHITECTYIE Date 93ARContnctor YI2DO ANTSOZI understand my place shall be ublic men OVER 1000 AMPS /' SQ.FT.ROOR AREA B/SQ.FT.
z�j Licensed Professional SIGNS ELECTRICAL E D ' w . l
6 OWNER-BUILDER DECLARATION SPECIAL CIRCIRT/MISC \ '\Y,
R
Iherebyaffi mthat[am exempt fromthe Contractors Llcesse awf¢the N.. a.�
ZO 7 following reason.(Section 7031.5,Realness and professions Cade:Any city or TEg.1p,METER ORIOLE 1NST. IE ,�'•'ij
t"' ro.ntywhlchrequimapermittommtmd,alter,improvcde=o h,orrepalr
�� Cal anystmMmprlortolbiswance,alsorequimtheappliantfors.chpermino DAT 9gse3
r u Ole a signed statement that he b licensed pursuant to the provisions of the InWF.R DEVICES
w Contractors License law(Chapter 9(cammenclog with Section 7000)of Divi- �-
SWPIMING POOL ELCCTRIC
sion3o(the Budnessand lsrofesslonsCode)orlhat he lsazempttherc(romand VA 070#
¢ the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLE SSSWITCHFSFIXTURES
room �� I•aO ..—G
applicant fora permit subjects the applicant to a dv11 penalty of not than VV
w � five hundred dollars(S500). NEW RGS[DENTIAL ELECTR
71,as owner of the properly,or my employees with wages as their sole --SQFr. STORIES TYPE CONSTRUCTION
compereallon,will Bothe work and thestmcture is not Intended or offered for
M saIs&c.7064,Business and Professions Code:The Contractors License law
t $ docs not apply to a,owner of property who builds or improves thereon,and OCC.CROUP R}UNUS
0.0. who doessuch work himself orthrough his own employees,provided that such
Improvements arc not Intended oroffered for sale.If,however,the building or TOTAL:
Improvement 0 sold within one yearofcomplMlon,the owner-buRderwlll have ..
tt)oburdso of proving that he did not buBd or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD TONE APN
LL�J),as net
of the property,am exclusively contracting with 11¢nsM
contractors to construct the project(Sm 7044,Business and Professions Code: PERMITLSSUANCE
The Contractor's License Law does n¢apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
Wilda or Improves thereon,and who contracts for such Ed
(ojes with a
cgBt(actor(a)u¢nsed purseand to the Contractor's L1¢nse Law. BACK PLOW PROTECT.DEVICE FEE SUMMARY
LI I am exempt under Sm w
B k P C for this rean �OUTSJDL RES
Owner Date
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
WORKMAN COMPENSATION DECLARATION HXTURES. RPER TRAP SCHOOL TAX Y N
01 hereby affirm that I haw•¢rtlfl¢te of convent to wl4inure,or RECEIPT
N
mrtiflate of Workers'Compensatlonlnsunn¢ora¢rtifkd copy<M1ereof(Sec. GAS F.A.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,Lb C.)
Pollryp iDy9oia.� - t'
- _ GAS EA,SYSTEM-OVER4(EA) RECEIPT
CORA a^Y �Yn BUILDDINGGDDII)0
SIGN FRES
❑Certified ropy Ls heed with the
GREASE/INDUSTRL WASTE INTERCEPTOR PLAN=D.t,
^ V�
�CcrtlOed mpyis(iled with the city lmpedlon division, 4 J
CERTIFICATE OF EXEM PT ION FROM WOR KERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWFR-SANITARY-STORM EA.200FT. Reeel [#
ITho section need nor be completed i(t W permit b Ionone hundred dollars
($100)orlew) WATER HEATER W/VENT/ELECTR ENERGY F"' N
1¢rllfy that In the performance m
.f the work for this permit lsised, —
I shall not employ any person In any manner ex as to become subject to the WATER SYSTEM/TREATING .
Worker?Compensation Laws of Cal fomb. Date PAID
O Z Applicant
_Z p NOTICE TO APPLICANT.ft,after ma king this Centlfiate of Exemption,you NEWRESIDENTIALPLMB. SQ.FT. ate Recei lac
should become subject to the Workers'Compensation provisions of the Latour TOTAL:
I— y Code,you=at forthwith comply with such provisions orthis perrNtshall be
j deemed revoked.
BL NC •E i'
dCONSTRUCTION LENDING AGENCY - SEISMIC F• •
I hembyaffirm0et there is a construction lendingagency forthe perform- ELECTRIC ••E
n Z ancc.fthc workforwhichthb permit bm
bed(Sec.309'/,Civ.C.) TOTAL:
02 Lander'.None � PLUMBI FEE
IL I- I<ndcr.Addmw QTY. ' MECHANICAL PERMIT FEE MECHA TEL FEE
O Ed
Icedifythatl have madthls application and gatethallhe above information
(d is correct.I agree tocomply with a6 city and countyonB^ancesand state laws PERMIT ISSUANCE FEES PA D:
>. reI.d.g to building commockhm,and herebyauth^rba repreentativea of this
Zcity to enter upon the above-mcntlomd property for impection purposes. ALTERORADDTOMECH.
(We)agree to save,Indemnify an d keep harmless the City of Cu pen int, Date Receipt#
V against liabilities,judgment,costa and ezpenw��vhlch maylnanywayaccrue AIR]CANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against i sequence !t grant Rg fthls permit.
AIR HANDU NG UNIT(OVER IO,000CFM) CONST R ON TAX
SI a1 rea(Applia^t/Contractor Date hXHAUS"THOOD(W/DUCD CONSTRU ION TAX PAI
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hanrdous HEATING UNIT(TO 100,000 BTU) Date RC #
material as defined by the Cupertino Municipal Code,Chapter9.IZ and the
Hes Itis and Safety Code Section 25532(.)? HEATING UNIT(OVER 100,000 BTU)
T L[
E-1 ye. M No
Will theappliant or future bedidbg occupant...equipment mdevices VENTILATION PAN(SINGLE REBID) ,ISSUA EDATE
which emit haeardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP D}IPOR 100,000 BTU)
PYes Q❑No
havem.dtheh. .sma(crisis requiremmeeunder Chapter 6.95of BOILER-COMP(OVER I00,ODOBTU) �s E
the Celifemia Health 4c Safety Code,Sections 25505,25533 and 2x534. I Al 9
ID
understand that if the Wilding does nor currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQFr
responsibility to notify the occupant of the requirements which most be mel 1��Y i9 1993
prior to issuance of a Certificate of Occupancy.
Owner or authMud agent Date I59U0,dtt U (
TOTAL �W/ ---.����
OFFICE COPY