24180 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification Ph1(hEPNQ, 4180
6ullding Address:
r CAS 9&V=:I,
Wne(s stile. one.
ITAL DA tii
CITY OF CUPERTINO-BUILDING DIVISI -
ContraRor'aName: Llc.No APPLICATION / PER
BUILDING ELECTRICAL PLUMBING CAL CATEGORY C Qpr
Arc Item/Engineer' Lk.N v
SZ G— C• BUILDING.PERMIT,INFO
:ELSG`fRIC• R .--.:'FEE
Address: �/ S f/f es PERMITISSUANCE 1��..1I ❑ ❑
LICENSED CONTR CTOR'S INVELARATION yJ .
Ihereby affirm that l am licensed under provisions of Chapter 9(commem, AP ANCW DENTIA OB DFSCRE'TTON.
ingwlth Section7000)ot Divbian3ofthe BumneseandPro(esslonsCbde,and my
license is In full fyy Band effect P
LlrenseClass 17 LIc.M 437
Date q-yf�Contraathr /�f ,
ARCHITECTS DECLARATION 1-1000 S
�O I understand my plans shall be used as public records. OVER DAMPS ,t, i� SQ. } R RFA J INJ $/SQ.FF.
Licensed Professional NS ELECTRICAL r7 R
6 OWNER-BNLDER DECLARATION
o IherebyafRrtntOW ass exemptfromthe Contraror's Llan.Lawforthe 51'ECIAL CIl2CUIT/MISC Li' y� I, �y
ZOZ'a following reason.(Section 7¢113,Business and Professions Code:Any city or, TEMP.METER OR POLE INST.
�4 countywhichrequlresapermittocomtmdaitegimpmve,demolbh,orrepalr
g anystrucumo prlorto Its Issuance,alsorequirmthe applirantfor such permitto POWER DEVICES
k5 file a signed statement that he Is licensed pursuant to the provisions of the
Qb3p,N Contractor's License Law(Chapter 9(mmmencing with Section 7000)of Dtvl- SWIMMING POOL ELECTRIC
SOS sionil ofthe Business and Profmalors Code)orthat he is exemptlherefromand VALUATION ?-
O the basis for the alleged exemption. Any violation of Rection 7031.5 by any b OUTLETSSWITCHESFIXIURES C D�� t
applicant for a permit subjectsthe applicant to a civil penalty of not more than
u, m five hundred dollars($500.
L as ownerofthe property, NEW RESIDENTIAL ELECTR SQSr. STORIES 711'E CONSTRUCTION
e hp rty,or my employees with wages as thele sale
compensation,B.shimwilldo he work andthe structure,Code:Th Contractoror or icatue d for
Law
O sale(Sec.7W4,to an owner
f property
Code:The or improves
License Law
whoa not apply to an owner d property who nbuilds or Improves thereon,and
who doessuch whrk Mrtsel(rnthrough hisownemplayees,provided thatsuch OCC.GROUP RFS.UNITS
Improvements are not Intended oroffered for sale.If,however,the building or T WV
Improvement is sold within one yearofcomplellon,the owner-bullderwlli have . ,
tryQ_L,rNen of proving that he did act build or improve fee purpose of sale.). QT^[; PLUMBING PERMIT'• ".FEE ` FLOOD ZONE APN
"L as owner of the property,am exclusively contracting with licensed Y pFRMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
builds or improves thereon,and who contracts for such'p(ojety with a
��tt($actor(s)licensed pumuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE "FEE SUMMARY
c(51 am exempt under Sec, B k P C for this reason
Owner Date
DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y N
re RECEIPT
N
WORKMAN COMPENSATION DECLARATION FD(TURES PER TRAP SCHOOLTAX Y N
❑1 hereby affirm that I have o certificate of convent to self-iher or RECEIPT M
3800,Uteo(Workers'Compersatlon lrsuranreora certified copythereof(Sec. GAS EA SYSTEM-1 INCA OUTLETS � PARK FEE Y N
380Q Lab C. 7
Collry M 9 �a3 7� / ( RECEE'C N
CAS EA.SYSTEM-OVER 4(EA)
Cwifi_ cop '1 - _ BUILDING DI VISI NFBES
�(ified copy is heed with the
GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑CertUied ropyb(iled with the city impaction division. C
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID 4OJ
COMPENSATION INSURANCE SEWEILSANTTARYSTORM EA 200Ff Date a [#
Ohlssection need not he completed if the permit la on
thre huntlred dollam
($1I artifess) WATER HEATER W/VENT/ELECTR ENERGY FEE Ylet:eiptlf
N
Icertl(ythat In the performance of the wrnkfor which this permit is belied, —
I shall not employ any person In any manner so as t ^ro cur jg-R to the WAIPR SYBTEM/TREATING
Workers'CompenssL�tion laws of Calif o la.Date l.. PAID .
OZ Applicant G+S CWA-1,Sam
Z O NOnCE TO APPL NT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL FLAIR. SQ%.
should become subject to the Workers'Compensation provisions of the LaborOTAL:
U9 Code,you must forthwith comply with such provisions or this permit shall be BU FEE
W j deemed revoked.
d c CONSTRUCTION LENDING AGENCY - S I FEE
!hereby affirnthat there is a construction lending agency for the perform ELEC RIC FEE
Z arse piths work whkhthb rmmyY biassed(Bac.3097,Civ.C.) TOTAL
(� O Lenders Name n�a/A - - PLUMBING FEE
LL t— wonders Address QTY: '°MECHANICAL PERMIT cr:FEE'.;' MECHANICAL FEE
OW Icertitythatl have read this application and s[atethattheaboveinformatlon
IL Is correct l agreeto complywlth all cityand county ordinances and mate Is" PFRMTTISSUANCR FEES PAID:
} relating tobullding construction,and hereby authorize representatives ofthb
F Z city to enter upon the above-mentioned property for lospeaton purposes. ALTER ORADDTO MECH.
— (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Rece t#
against liabilities,judgments,comaand expenses which may In anywayamme AIR HANDLING UNIT OO 10,000 CFM) $UBTOT
again�st sad�//J ity M conseu the granting of this permit. '
>94d," ,v�fi/ O� �,_,�` AIR HANDLING UNIT'(OVER 10,000 CFM) CONSTRUCTION TAX
Slgnaminne oofff Applicant/Contractor Date EXHAUSTHOOD(W/DUCT, CONSTRUCTION TAX PAI
HAZARDOUS MATERIALS DISCLOSURE
-
Willtheapplicantorfuture building occupant store or handle hazanicas HEATING UNIT(TO 100,000 BTU) Date Reeef I#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
I9calth and Safety Code Se 25532(a)2 HEATING UNIT(OVER 100,000 BTL) TOTAL'
❑Yes b chef'
Will the applicant or future building occupant useequipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hazardhus air contaminants as defined by the Bay Area Air p '
Quality Management Distrl BOMEROOMP OHP OR 100,000 BTU) K
4 Ye.
haveread the has pus materials requirements2553aChapter.1 of BOILER-CAMP(OVQt 100,000 BTU)
theersiandta Health bSafety Code, of currently have a Land,that 1 SEP 23 1992
understand that n notify
the occupant of t emqulyments which
that it met NEW RESIDEN77AL MECH. SQ.I•T s.'�yL
responsibility to notify the occupant piths rcquircments which must be met
priortoles ceof Certific of Occupancy. IIVV
1l/�riin/XP.� 7-9Z \�\C]ITYVQr' �r
Owner or.authorived agent Date TOTAL: ISSUED BY:
OFFICE COPY