24207 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Praect Identification PERMIT NO
eIkI(."°a ,� 24207
J erg y one: E.
CITY OF CUPERTIN66UILDING DIVISION r q
Contactors Name: Lie.Ne: APPLICATION I PERMIT �j C
Arehltent/Englrser. Lk.No: BUILDING-ELECIWCAT ML BING-MECHANICAL CATEGORY CONTROL Y
'QTY - ELECTRIC PERMIT FEEBUILDING PERMIT INFO
Address - PFRhIITI55UANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby thSmdoaffirm'hat).fDi licensed 3.ftheunder B.Sir.v .deaf Chapter 9(mmmenc- APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingweh In fon force of Divfect. the Bualneuand ProleaUaneCode,and my
license Is In full force and effect PANELS -
LlcenseCbss Llep �LQ
Date Contactor �`��(;•�e
ARCHITECTS DECLARATION 201.1000 AMTS
go I understand my pians shall be used as public records. OVER IOW AMPS SQ.FT.FLOOR AREA S/�.FT.
U E Licensed Professional SIGNS ELECTRICAL
6 OWNER-BUILDER DECLARATION SPECIALCItCU1T/MISC
t., Ahem affirm tl am exempt fromthe Contractor's License Law for the / I 7
7 pp following reason.(Section 70315,Business and ProfessTDes Code:Any dty or v �� �J L J t 'I a pp`.'.�(
O y" T[MP.MEIERORPOLEINSI. u L L.J E Y l
p4 oountywhichrequlmaperrrdtWmmu cyalter,lmpmve,dennlbh,orrepair
anystmctumpdortoiwbmance,aborequim.theappliantformchpermltto POWER DEVICES
�i file a signed statement that he is licensed pursuant to the provblons of the DATE
Contnctorb License Law(Chapter 9(mm
mentl700D
ngwllh Section )al Divl- SWIMMING POOL ELECTRIC L. VALUATION
sion3 oflheBusiness and Professions Code)orthat he is exempttherefromand
Q the basis for the alleged exemption. Any violation of Section 7MIS by any OUTLETS—SWITCHES FIXTURES
applicant for a per cat subjeda the.pplicant to a civil penalty of no moa than
five hundred dollars(:W. SQ STORIES TYPE CONSTRUCTION
�n as owner oI the property,or he employees with wages r thele sole
NEW RESIDENIiAL ELECTR .FT.
t m(Sce,7len,Business and
Code:The
offeredLaw
$ sale(Sec aptly to alnowandfpropety Cade:The Contractors LicensDlaw
S whododoes net apply lnan owner ofpnough who
nemporlmprovnled thatand OCC.CROUP RES.UNITS
who does suchwork himself orthrough his own employees,provided that such
Improvements are not Intended oroffered forsale.If,however,thebuilding or TOTAL:
Improvement bseld within one yea rofcompletion,the owner-buliderwill have
to rden of proving that he did not build or improve for purpose ofeale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE MIN
LJ L as owner of the property,am exclusively contracting with licensed
contractors,to construct the project(See-70K Busineav and Prefeselons Code: PERMIT ISSUANCE
The Contractor's License law does not apply to an owner of property who ALTER-DRAIN 6 VENT-WATER(EA)
Wild. or improve,thereon,and w contracts for such p,icen.with a
co I.ctods Icx..d Pum ant toth tractors License Law. FEE SUMMARY
BAIX FLOW PROTECT.DEVICE
empte Sec B k C for this rcaeon
r, OUTSIDE FEES
DRAINS FLOOR ROOF,AREA COND. SANITARY Y N
err ale RECEIPT p
WORKMAN ION ECIA ATI N pI%'IVRFS.PERTRAP SCHOOL TAX Y N
hereby affirm that 1 have a certi(kate of con t to wlf-Imst ,ora RFCE[IPT p
certificate of Worked'Compensation Insurance era certified copythereof(Sec.
3800,Lob CJ GAS EA.SYSTEM-1 INCA OUTLETS PARK Ff:E Y N
Policy Y CAS G.SYSTEM-OVER 4(FA) RECEIPT a
CUM B UILDI.NG DIVISION FE ES
Coddled copy is heed with the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Coddled copy billed with the city Inspection division.
CERTIFICATE OF E(EMPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-SIORMEA.2(X)FT. Date ReEm HI
IThbuWctlon need not complmnd Uthe Permit b n,Toruhundred dollars
(8100)oslc.s.) WATER BEATER W/VENT/ELLCTR ENERGY FEE Y N
ce
I rtifythat in the performance otthe work lorwhlch this permit is timed, —
I shall not employ any person In any manner au as to become mbjed to the WATQt SYSTEM/TREATING
Workers'Campensadon laws of Cahf..ia.Date PAID
-
Z
Z ApplicantNEW RESIDENTIAL PLMB. SQ.FT. Date Recei til
O N0TiAPPLICANT:If,after madding this Certificate o(Fxemption,you
U
become.ubpe to the Workeri Compomatlon Provisions of the You
TOTAL:
CC D Code,you=at forthwith comply with such provisions or this permit shall be U IN
`> deemed revoked. FEE
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Iherebyaffirmthat thea b a construction lending agency for the perform- ELECTRIC FEE
M 2 anmoftheworkforwhlchthbpurMtb Weed(Sec.3097,Civ.C.) TOTAL:
00 Lender'sName PLUMBING FEE
LL F Lender'sAddm. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE .3,D
OW Icertifythat l have informationad lhisapplicatlonand statethat theabove information
O. Is current.(agree to comply with all city and county ordinances and state law, ' PERMIT ISSUANCE IS-DU FEES PAID:
>. N relmingwinlldingcoestmction,and hereby authorize representatives o(thb
Z city to enter upon the abovcmentloned property for Inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,IndemNfy an d keep ha ess the City of Cupertino Date Reeei tit
�••� against llabill dgencra,costsand expenses hmayfnanywayaccme AIR HANDLING UNIT(1'010,000 CFM) SUBTOTAL: ,/1
.gal i I In consequenceo agr i h permit. I
AIR HANDLING UNIT(OVER 10,0DOCFM) f. 00 CONSTRUCTION TAX
105160
SI fur pp can Conte dor Vie EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or ha le hazardous t HEATING UNIT(TO IDJ,ODO BTU) . OD Date REtel tN
matcrlalas defined by the Cupertino Municipal Code,Chapt 933 and the
Health and Safety Code Section 2S532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: 3• DQ
Yu No
Illthe applicant m mmbulldingo pantueeequipmantordevices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
\../ whlcheManagement,mtrict? Mnan[a as detlned by the Bay Area At, PAID
Quality Management ahe ❑l,col BOILGR-COMP(3li)'OR 100,000 BTU) y
qYes. rJ No
have to lealth& et Code,Se regn's 25505,25533
55 nts 5,2553ernd 2S5 L I of BOILER-COMP(OVER100,000 BTU)
the
.rulersunnlaiieith kSafsty Code,not
have a tenant,
d25hatIt SEP 15 1992
responsibility
that lithe the ing doesoccupant oft a currently which
that it mot NEW RESIDENTIAL MECH. SQ.FT
mor to ev a to notify the occupant o!the requirements which must be met
prior to Issuance uta Certificate of Occupancy. ���[f3111gV
Owner or authorized agent Date cri I Ur oGLu ,
InrnL: ,OD ISSUED BY, �
OFFICE COPY