22848 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prmcd Identification 7 PERMIT NO.
Building Address; 0 8 A O
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/✓ APPLICArUR7UMMrA CQlu'2Q ?07 �O(� CITY OF CUPERTINO-BUILDING DIVISION Q_�_n
C°^lra :. (J1 �g{ry�) APPLICATION /PERMIT
V4 BUILDING-ELECTRICALPLUMBING-MECHA MCAL CATEGORY CO
Architect gl^j�r. L / C.
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addrea..b 5-. GLI C'4a1/
I'FRhRTI55UANCE [> ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION l�'
IhthSy on7OMat Divisiam ensed 3ofthe ur nromalonso(nsimsr9de,and APPLIANCES-RESIDENTIAL JOB DESCRIPTION
in ease I.Infon innocent]
t]effeon3o(the Bustnessand PmfeaslonsCode,and my S E�se�
license b in full force and a(ect, PANELS
Date Claes Contr V
Date - Contractor
ARCHITECTS DECLARATION 201-1 WOAMI'I
Ocq S � Al SQ.FT..
q�u 380 Zp I understand my plans shall be used as public records. I 6/�, Nb
H E Licensed Professional S(GNSEL
<H G IL�u OWNER-BUILDER DECLARATION yT'Pf.ULCIRCUIT TSCER
ZF IherebyaPormthatlam exempt(romthe Contract°r'sli...Lawforthe YYY
ppppq�( following reason.(Section 7031.5,Business and Professions Code:Any city or
' MPO
county which requires a permit to conhuct,alter,Improve,demolish,or repair TEMP.MEITR OR POLE INST. E _\l /�/��
a any structure prior to Its issuance,also requires the applicant for such permit to POWER DEVICES U5
\a /
1 O V flle a signed statement that he is licensed pursuant to the provision of the
�µ Contractors License Law(Chapter 9(rommencingwith Section 7000)ofClot.
�Os slon3ofNeBusnnsand PvesslonCode)orthathebexemptherefromand SWEdMNGI40LELGCRC VALUATION
�^J_ the basis for the alleged exemption. Any violation of Section 70313 by any QO
< OUTLETS-SWITCHES-FIXTURES M
applicant fora permit subjects the applicant to a dull penalty of nor more Than
a five hundred dollars($500). NEW RESIDENTIAL ELECTR �''IT,
M I,as owner of the property,or my employees with wages as their sok STORIES TYPE CONSTRUCTION
compensation,will do the work and the structure is not Intended or offered for
Osale(Sec.7094 Business and Professions Code:The Contractors License Law
$g does not apply to an owner of property who builds or Improves thereon,and '
who doessuch workhimael(orthrough hisown employees,pmvidedthat suchOCC.GROUI' RFS.UNITS
improvements are not Intended oroffered formle.If,hmvevep/hebuilding or TOTAL:
improvement Issuld withinoneyearofcompletion,the owner-builderwill have
0rJardenofprmIrg that he did nor build crlmprove for purpoaeofsale.). QTY, PLUMBING PERMIT FEE
11 L as owner of the property,am exclusively contracting with licensed FT-OOD ZONE APN
contractors to construct the project(See 7099,Business and Profession Code: PERMITISSUANCE
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN 9c VENT-WATER(EA)
Wilds or Impmves thereon,and who contracts for such projects with a
cgR(pctor(s)hoemed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LI I am exempt under Sec. B k P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SAMTARY Y N -
Owner Date RECER'Ip
WORKMAN COMPENSATION DECLARATION RO(.DJRE&PER TRAP SCHOOL TAX Y N
[-]I hereby.,flan that I have a cediflate of consent to self-insure,ora RECEIPT j7--
Flo
3800,ateo(Workers'C.-o'7mpevatlonlnuran orace0lfled copythemof t5ec. GAS EA.SYSTEM-1 INC OUTLETS PARK FEE Y N
3x00.Yb CJ / 0 %(� 7 9 / / RECEIPT N
Crim aZ� /' C C�dPM , e I CAS EA.S'YSTEM'OVER 4(EA) BU I LDI NC DIVISION Fr.FS
editled copy is hereby fumished. T
MCedifiedcopyis(Iled Mththedty Wpedio^division. GREASEANDUSTRL WASTE INTERCEPTOR P CK FEE
CERTIFICATEOF P, EMPTION FROM WORKERS' GREASE TRAP PAID ��
COMPENSATION INSURANCE SEWER SANITARY STORM EA.200FT. Date Recei f#
(Thlssedion need t a be completed lithe permit U foron hundred dollars
($10°)°rfy that WATER HEATER W/VENT/ELECTR ENERGYFEE Y N—
I
loss.)
Iu the performance of the work for this permit le sussed, —
I shall not employ any pera°n N any manner n as to become subject to theWATER SYS[Eh1/,I7tEA,DNG
Workers'Compensation Laws of California.Date PAID'
O Z Applicant
Z NOTICE TO APPLICANT:If,after 0uking this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
O should become subjea to the Worlu s'Comperwtlon provision ofthe Labor TOTAL:
� N Code,yma at forthwith comply withsuch provlalonorthis permitahallbe B 1 DN
deemed voked.
LU
C reCONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby afflrmthat there H a construction lending agency for the perform- ELECTRIC FEE
:3Z ance of the work(or which this permit is Issued(Sec.3097,Cls.C.) TOTAL:
U O Lender's Name PLUMBING FEE
LL Undersnddreas QTY. MECHANICAL PERMIT �E MECHANICAL FEE
O W I cedllythat l have mad thisappliettionand statethat the above Information1 bcorred.Iagreetoe°mplywith all cityand countycedinanoesand state laws PERMIT ISSUANCE FEES PAID:
} y ectingtobuildingcontructlon,and lorchy authorlu representativesotthis
Z city to enter upon the above-mentioned perry for Inspection purposes. ALTER OR ADD TO MFCH.
(We)agree to save, mnity and ep harmices the City of Cupertino Date Reeei t#
V against liabilities,P ts,costsan pen which ms ylnanywayaccrue AIR HANDLING UNIT(TO I0,000CFM) SUBTOTAL•
a ahsta ity in uenceo(t ant athb permit. t
AIR HANDLING UNIT(OVER 10,OWCFM) CONSTRUCTION TAX
Slgnatu ppLiant/Con actor Date EXHAUSTHOOD(W/DUCT) - CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,ODO BTL)
maDate ReCei t
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Ifealth and Safety Code Seaton 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOT'
❑ Yes No
Will the applicant or u=building occupant use equipment ordevices VENTILATION PAN(SINGLE RESID) #SSAAVU DATE
which emit hazdrdow air contaminants as deflned by the Bay Area Air
Quality Management District? BOILER-COMP QHP OR 100,IX0 BTU)
Y' 4"° MAY 11
have read the haaa[( is No.
requirements Chapter of BOILER-COMP BTU) 1('92
the California Health k Safety Code,Sections 25505,25533 and 75539.1 ss779
understand that if the building docs not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQJ-7
responsibilityto notifytheoate of cof cupa requirements which mnustbenot CITY UI- (,UNenl I I VU Prior Issuance ofiy the ccs aOmhe cy.req
Owner or authorized agent DateISSUED BY:
TOTAL:
OFFICE COPY