20832 APPLICANT TO'FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT,PEN ONLY..
Building Project Identification _, PEItMITN20-832
•O/. -
." buil,ng Address: - - 0 8 3 Z
o I SLo 7--r 'Y
wners ame: - - one:
My ItMV-S k9"9 WtL/a` • 44e-62"O CITY OFCUPERTINO-BUILDINGDIVISION 9,
can actor's Nag, •a� Lie.N.' APPLICATION /PERMIT -
s• ' BUILDING-ELECTRICALPLUMBING.MECHANICAL CATEGORY CONTROL It
Architect Engineer: s Lic.No:
- QTY 4+,' I t E C C PERMIT � i 1�1 +FEE k- ' 't'BUILDINC PERMIT.INFO
Address: , PFRMITI 4� %Fvq ❑ 1:1LICENSED CONTRACTOR'S DECLARATION -
I hereby affirm that l am licensed under provisions of Chapter 9(commnnc AN - JOB DESCRBTION
'ngwith Session 7000)of Divislon3otthe Businnsand Profestl.nsCode,and my
license is In fou ra d effect
LlanUsa: ^Clic# c
Date 1r r7- Contractor S�s lJ` l "VVV-••Y-LL
ARCHITECPS DECLARATION I006
-
uOw Zp l understand my para shall be used as public reads V R1 r SQ.FT.FLOOR AREA $/SQ.FT.
mm V�j Licensed Professional sicN$ELECTRIC -
<Z, OWNER-BUILDER DECLARATION
1i,a SPECIALCIR LSC
E,u3 I hercbyaffirm that I am exempt from the Contractor's Llrense Law for the
Z 0_ following reason.(Section 7011.5,Bualnen and Professions Code:Any city or
FZF
whir lp t improve, ah, r r
TI PMEROR
POLEINST.
..y.tuu.p .rt.i handaocoquimthentforsett
file a signed statement that be,6 licensed pursuant to the provisions of the POWER DEVICES .
'
C.ntnctore Law rommendn
Lia.L (Chapters( gwithStolon7000).(Dlvl-
SWB.ShENC I[30L Fd.
ib V,, .
`b�< sron3o(the BueinevnndPMemioruCode)orthat heaeumpttherelromand ECTRIC - VALUATION '
IE3o5 Q.sl the hash!or the alleged exemption. Any violation of Section 7Ri1S by any OUr1.ETSSMTCHPSFIXRIRFS
d
applicant for a permit subjects the applicant to a civil penalty of ramorethan x "• ( V��
$ five hundreidolars(SM. NEW RESIDENTIAL ELI:CTR FC,
.. ❑I,as owner of the property,or my employers with wage es lhclr sole SQ STOW ES TYPE CONSTRUCTION
C 6 compo.7044,Business
and Profesthes Code:The
Contended.License
Law
D seaISot apply
Bualnen andf property
Cade:The Contractors Clave Gov
$ don not apply tosnownerofProperty who buildnem firprooes and - OCC,GROUP RES.UNI'CS
who does
mentsa net
or.ugh his awne.If,ployees,
providedthat
or such .
Improvements am not Intended.coffered forme.IL howeveq lhebullding or TOTAL:
Improvement issold wlthinoneyearofcompletlon,the owner-bullderwlll have -
thq*rden of proving that he did not build s Improve for purpose ofsale.). QTY. t' �',PLUI1•I BIN G,PERMIT•'. FLOOD ZONE APN
LJ L as owner of the preperty,am exclusively contracting with Banned PERMIT ISSUANCE -
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractor's License law does seat apply to an owner of property who ALTER-DRAIN kVENT-WATER(EA) _
Wilda or Improvn thereon,and who contracts for such pwimu, with a
offactor(s)Brenad pursuant to the Contractor'.License Law. =FEE SUMMARY"., '
LJ BACK FLOW PROTECT.DEVICE
I am exempt under Sec. B k P C for thin reason OUTSIDE F1 I S
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION
❑ ffirm that I have a arti0cate of consent he Fp(.I.URF.&I'ER.f.RAP SCItOOL TAX Y N_
I hereby aself-Insure,or
46maiRECERECEIPT#
fimteo(Worker'Comperuatlonlmuranceoracertltiedcopythemof(Sse. GAS F.A. YSTEM-11NG6OUTLETS PARK FEE Y N '
I. 3800,Lab C.) -
PoI1ry N GAS FA.SYSTFM-OVER 4(FA) RECEIPT#
Com a BUILDING DIVISION FEES.
edified copy is hereby furnished. GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
= Certified copy a filed with the city inspection division.
CERTIFICATE.OF Fd(EMPTION FROM WORKERS' CREASETRAP ,PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA.200FT. - Date Remi t# -
IThiesed not be completed If the permit.for one hundred dollar
(S10o)orlons.)lessdhis WATFRHEATERw/VFN'f/ELiicTR ENERGY FEE Y N
I snotrtify that In any phe erson
In
tmannerhe work sa a towhich become
is to th, —r
I shall not employ any person In any manner w n to become subject to the WATER SYSTEM/TREATING '
Workers'Compensation Lanae of California.Date -. PAID-
' Applicant '.. . .
Z NEW RESIDENTTALPLMB. SQ.IT. , ., Date Recei t#
ZO
NOTICETOAPPLICANT:e akermaking rs'Cotha Certificate of Exemption,you
sM1wldbecomn eforth forto thwith
co ply with
such prsatlonprovhis per it s Labor TOTAL:.
W~ N dannedrevokeforthwith comply with such provalona ortha permit shall be
> deemea revalma. BUILDING FEE - t
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE �1
Iherebyaf(Irm that there Is a comtmalon lending agency for the perform TOTAL: ELECTRIC FEE • -Lt C1C1
Z - anceoftheworkforwhlchthlspermitisinued(Sec.3097,CIv.C.)
U O lender.Name FEE
U. Leader.Addreae QTY, I, I MECHANICALPERMIT 1, ul?.FEE,•`, MECHANICAL FEE
.O W ' lredifythatlhavem.dthaappllntlonandalatethatlheabbvelnformation
a Barrcct.Iagreelocompiywith all cityand countyordinancnand statelaws PERMIT ISSUANCE FEES PAID:
HZ ci(Wenter
eeupon to theabovemnify an
n d property nessthe Cit purposes.of Cu
ALT[R OR ADD TO MECH. - Date Receipt#.
_ (We)agree to save,Indemnify and keep es which
the in
of Cupertino
agalraHiabiWas,judgments,costs and expenses which may in anyway name AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
ASA Wt said City in consequence of the gra ning of this permit.
AIR HANDLING UNIT(OVER 18,888CFM) - CONSTRUCTION TAX ,
Signature of Applicant/Contractor Date EXHAusT HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 10(),000 BTU) .Dale Rfeel t#
1, material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
He❑alt Yaennd Safety Code,SenNtloon25532(a)7 HEATING UNIT(OVER IWOM BTU) - - TOTAL: 4SO
Willtheappliant or❑futvm Wildinjampantuseequipment ordevices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE.
which emit ha'rardou.air mntaMoante as de0ned by the Bay Arca At,
Quality Management District? BOILER-COMP OEB'OR 100,0(013TU) rj�la�
4Yrs �No PAID,
haiforia tealth& (icyus Code,ls Sections
2555,2553 and 255348.95^! BOfLGR-COMP(OV[R]00,f1(p B1U)'
the Calunderstand
tat lith A building
Code,Sectlma currently
have
a and tenant,that i 1 �`p (]
understand tht.outify the ingdces^cat erejam untswichthat It met NEW RESIDENTIAL MECH. SQ.FT. JUL a,Ir 19P
rap.n';Ity to ndify the occupant of the rcqulremenu which mustMmet - _ '
P= uance ofa Certiflcat of Occupanry.'
CiN4,sof,,runprtiiany�
ChanIlroraut,
izeda nl Date ISSUED BY:
LT TOTAL:
OFFICE COPY
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C6LLE12 :TZE'5 - 9" ON CENTER
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==:�UERTIN.FO CA 95129
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ia�r�i�uVETi
IN ACCORDANCE WITH THE CITY b�
CUPERTINO CODES AND ORDINANCES
DATES
SIGNED -fa_ moi( ZAP t 0
this set of plans and specifications MUSI \
be kept 0h the iob at all times and it is un
lawful to mai§ any ci1811.908 or alietatiuns
an same withc•ui w itten pa:m.ssion Iran D
the building LCay of Cupp t:no,
of y �l HERE(� E � M E
The stamping ci the p.ct<)n nd appcir;cationf { ( U
SHALL NOT be led t pc and c; t„ De an AUG 1 19"90approval of the roloticn ut any provisicn�
of any City Ordinance cr State Law.
BLDG. INSPErNION DEPARTMERT.
My,, OF CUPERTINO,
OFFICE Cupp