23265 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY "
Building Project Identification PERMITNO.
Bn103)0'0 S+D 23265
w'�r) hone: A A
1't• Q — CITY OF CUPERTTN0.6UILDING DIVISION
APPLICATION I PERMIT `TAT[►
CATEGORY CONTROL
BUILDINGELECTRICALPLUM9INGMFGHAMCAL
Architect/Engineer. Lie N.
4'QrY • v , ELECTRIC PERIv1ITi' i' I' FCC ; 1 ` '•i`r.�BU1LDINGPERMIT INFO,
.... . ,w . .... .CI . .
JIL
Addreae: •„ � -, '
: LICENSED CONTRACTOR'S DECLARATION PIRMITISSUANCE
(hereby a(firmthatlam Bcmaed underprovlalonsofChapter9(rommm APPI]ANCFSRESIDENIAL JOB DES(RIUPION
dnense1 inc 7000)0 deff(on3W� d.f"
e,aed my
Lice lain 11 deflect PANELSLice Cis LICM
DatatraCHFIT ARCHITF. 201-1000 AMf5
OZO I understand my plans shall beOVER I"AMPS - - SQ.FT.FLOOR AREA f/SQ.FT.
iqqPu± SIGNS ELECTRICAL /
E (Oj
Licensed Professional -
. <6 OWNER-BUILDER DECLARATION SPECIALCIRCUP_IT/MISC • -
ZI.,�4 IEimmlya(ttrm thatlamexempt from the Contractor's License law for the n n ..r�.,�
OO Q following reason.(Sedion7m1.5,Businewand Pmfess1ma Code:Anycityor p�11'I NC IL'r�
pz~ connlywhkhrequimsapermittocomtmd,altepimpmve,demolbh,ormpair TEMP.METEROR POLE INST. '
O any awdvretatemeltshat the us licensed
requires dpursuant to the formchpermit e + POWERDEVICES 4, 9�
file a signed statement that he 611cenved pursuant to the proWlons,of the i /CO
Contractor:License I..(Cha(Chapter 9(commencln wlthSectiun7000)ofDwl-
3 W t SWfMMINC IC]OL F7.ECIRIC i
theLIME
basis for
the
xempdon. Any violation Ls exempt therefrom and - VALUATI r
the basis for the alleged exemp[lon. Any violation of Section 7031.5 by any OUTLETSSWITCIiESFIXTURFS - - -
applicant fora permit subjects the applicant to a civil penalty of not mare than
five hu ndred it ollam(S500). NEWRFSIDENTIALELECTR SQFr. STORIES TYPE CONSTRUCTION
7�n ❑1,as owner of the property,or my employees with wages as their sok
compensation,willdo the work andthestructure is not Intended or offered for
OIn(Sec.7094,Business and Profemluro Code:The Contractors License Law
({3$ - docs not apply to an owner of property who Wilds or improves thereon,and OCC.CROUP RES.UNITS
C: whodoes such work himselforthrough hisown employees,provided that such
improvements am not intended oroffered for vale.If,however,thebuilding or TOTAL:
Improvement 6nald withinoneyearofcompletlon,theowner-builderwill have
t) furden of proving that he did not build or Improve for purpose ofsaMJ. QTY. :. lc,NtiTLUMBING'PERMIT�,,, FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
centractors to construct the project(Sec.7099,Business and Professions,Code:
The Contractor: Law w does not apply to an owner of properly who ALTER-DRAIN kVENT-WATER(EA) -
Wilds or Improves thereon, and who contracts, for such p(ojects with a
_ m,,IIIIII((aeor(O licensed pursuant to the Contractor.License Law. ,,.14r„;141,, ,t;;FEE,SUMMXRY�
-- t_J I am exempt under Sea 'B k P C for this meam. - BACKFLOW PROTECT.DEVICE
OUTSIDEFEFS
Own Date DRAINSFIOORROOF,ARWCOND. SANITARY Y_ N
WORKMAN COMPENSATION DECLARATION RECEIPT N
\� hereby affirm that I have a certificate of consent to self-Insureor a FIXTURE_:PERTRAP SCI IDOL TAX Y atN
eo(Wor reCampe Stl nlruuranceoracerti do pythdvef(Sec. RFOEE'TN
•L ' GAS EA.SYSTEM-t INCA OUTLETS PARK= Y N
Pdicy tl ��sal/I '(/ l3 GAS-EA.SVSIT3t1-0VER 4(EA) RECEIPT N
Com any BUILDING DIVISION FEES
�Ccrtlfied copy. d GREASE/INDUSraL WASTE INTERCEPTOR PLANCHECK FEE
I�>!Enitied copybfi with he city inspection division., +
I� CERTIFICATE-OF EXEMPTION FROM WORKERS` GREASE TRAP PAID
COMPENSATIONINSURANCE
RM1laceaion need not bacompleted lithepermit btorooe hundred dollars
SEWE
(f100)orlde.) - eR-SANTTARYa IiEAI'Eft w/vFNTiSTORM EAELFOTR 200FT Date 'RCCCI t#
ENERGY FEE Y N
mawAT
_
_ 4I dutifythat m the perfo
nm ofthe work forwhichthl•permit is issued, . —
Ishall not employ any person In any manner eo as to become subject to the WATER SYSIEhI/TREATING
Workere'Copensation l...&CaBfomis.Date PAID
Z m
Z Appllcant NEW RESIDENTIAL PLMB. SQ.FT. Date RCcei t#
O NOTICE TO APPLICANT.If,eher making this CertBlate of Exemption,you
should becomevubjectto the Workers'Compereatlon provisions ofthe Labor - , TOTAL:
(�) Cede,you at forthwith comply with such provisions orthis pertNt shallW BUILDING .
W Q deemed revoked.
W 'CONSTRUCTION LENDING AGENCY - SEISMIC FEE
CL I hereby afftvnthat there Is a construction lending agency for the perform ELECTRIC FEE
D Z and,of the work for which this permit is Issued(Sec.3097,Civ.C.) 1, - ' TOTAL:
02 Lender°Name W PLUMBING FEE
1L h— lender.Address - QTY. .'',I MECHANICAL Ir,ERMIT "�! . FEE ECHANICACFEE
O W 'Icortlfythat ve madthi•application and s dethatthe above information
u cormd.la oc ply with all city and county ordinanceeand state laxer PERMIT ISSUANCE FEES PAID:'
n' relatingtob idln r natrudlon,and hereby authortm representatives ofthls '
F 2 etytoenter Pon above-mentioned property for inspection Purposes. AL=ORADDTOMECH. D21C RCCCI t#
V — (We)1 to Indemnity an d keep harmieas the City of Cupertino P
agaWtlhb'Itka,' g nK,cortsanle
caves whkh may In nywayaccme AIR HANDLING UNIT(TO ID,000 CFM) —SUBTOTAL:
agamstcal Cityi a soft ting o(thie pe
v AIRHANDLINC UNIT(OVER 10,000C E) CONSTRUCTION TAX
Sigwtum of Applicant/Contractor Date Da LAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MAT ALS DISCLOSURE
Will the applicant or future building oro pant store or ha nd le hazardous HEATING UNIT(TO 100,000 BTU) DO[C RCCCI t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
lkalthand Safety Coda Scdlon2S532(a)2 '� HEATING UMT(OVER 100,0001117U) TOTA
❑ Yee
MN. -
s Wllithe applicant or futum building occupant use equipmentFN
or devices VTILATIONrAN(SINGLERESID) ISSUANCE DATE
which emit haurdoue air conmmioants as defined by the Bay Area Air
G_ualfty Management DisMd7 NOILF.R-COMP PI-Q'OR100.000 BTU) PAID d I D
Y. ❑❑No W
havemad the th&SfutyC c,S ii..255cnbunder Chapte4.I of BOILER-COMP(OVERt00,000BTU)
theerstan that
hveataad,that
AUG
understandthat lRhe the occupant
oft the
yments which
that It met NEW RESIDENTIAL MECFL SQ.FT 1994?
ropotulbllity to notify theompant o(the requirements which must be met /s y
- -prior to Issuance of a Certificate of Occupanry. - CITY ut,
Owner or authorized agent - Date - ISSUED B
TOTAL:
OFFICE COPY '