23900 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT.PEN ONLY
Building Project Identification - - i PERMIT NO.
Bmlamg AaareB.:
2-3900
0 992., ScvE�"rp.4-KS
WMrB i /� One: p A
.7sZ: 4/0 7 CITY OF CUPERTINO,BUILDING DIVISION cA�
Contra or'B—Na'm1e:, Lk.Na APPLICATION / PERMIT -
I
�312IUR' 8 . BUILDING-ELWTRICAI.PLUMBING-MECHANICAL CATEGORY - CONTROL.
Architect/Engineer: Lic.Nee
,. t, ELECTRIC PERMIT )1{4$� �� ,pCEi.t '...BUILDING PERMIT INFO
Addrome ITS �rt PEPMIT199UANCE ❑ .❑
LICENSED CONTRACTOR'S DECLARATION
I hereby afftrm that l an,lkensud under provisions of Chapter 9(commene. APPLIANCES-RESIDENTIAL ]OB DB bn'1'I01s!
inenseISection force of Divfect. ofthe Buelnaaeand Pro(mlonsCode,and my �
license la a lull force and effect. PANES
License Clam Lic.If
Date Contactor UP TO 2DO ANTS -
ARCHITECTS DECLARATION. 701-1000 AMPS
pp!NO Zp . I understand my plans shall be used as publlcrerords. OVER1000AMPS SQ.FT.FLCORAREA $/SQ.FT.
�zz1�j Licensed Professional SIGNS ELECTRICAL
G 6 u OWNER-BUILDER DECLARATION SPECIALCIRCUIT/M19C
71., 5 IherebyatOrmthatlam exemptfromthe Contractor'BLlcense Lwr for - I-.. D
oo following reason.(Section 7011.5,Bu.inm and Prodel.r.Code:Any dty or e1 !M /7 �� r
P� countywhich requirc.a Permit construct,eller,improve,derellah,orrepair TFMP.METPR ORPOLEINST.
aeystructure price to its imseance,also requires the applicant forsuch permit to POWER DEVICES
a file a signed statement that he is licensed pursuant to the provisions of the
3µ Contractor's License ILaw(Chapter9(mmmenclng with Section 7000)of Divi. DAT n SWIMMING POOL ELECTRIC
SOS the basis for
eallegnd Tamption. Any
rthat lation b exemp therefrom any UA ON '
O the basis for the alleged exeisthea Any violation of Section no res by any OUTLEISSWITCHFSEXfURES -�
applicant for aperm(sub. the applicant too civil penalty of no more than -
/ivehundred dollam(5500). NEW RESIDENTIAL ELECT( SQFT. SIOWFS TYPECONSTRUCTION
o Q I,as owner of the property,or my employees with wages as their sole
compensation,wBl dothe work and thestmcture R not Intended or offered for
s 00 .1.(Se.7044,B.at.and Pmfmlom Code:The Contactors License law '
� $ does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP - RFS UNITS
_ who doessuch work himself orthrough his own employees,provided that such
Improvements..net Intended oroftered formic.K howevep thebuliding or TOTAL:
Improvementlsaoldwlthinoneyearofcompl&iogtheo ner-builderwillhave '
th�rdenof provingthat he did not build or improve forpurposeofsakJ. QTY,' l,q.,�„IPLUMBINGkIi MIT{' ,Pf ",ruE FLOOD ZONE APN
L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
mar-does to construct the project(Sec.7044,Business and Professions;Code: r
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
bunds or imp..tharon, and who mntram for such ploje s,with . ', ',FEE SUMMARY
sgDllactor(e)(ceneud pursuant to the Contractor'•Lkenae Law. BACK FLOW PROTECT.DEVICE 1•It ! '
Tj I am exempt under Sec. B &P C for this reason
FLES
DRAINS FLOOR ROOT,AREA,COND. SANITARY Y N�
• Owner Date RFiCEB'TM
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAX Y_ N_'
❑i he
affirm that I have a certificate of consent to self-Insure,.or a RFAEIPT X
certificate of Workers'Compensation Insurance ora certified mpy thenmf(See.
3800,Lab Cd GAS EA.SYSTFM-1INCA OUTLETS PARK FEE Y N
_
Policy If - GAS EA.SYSTE -CIVER4(EA) RECEIPT It
Co any - BUILDING DIVISION FEES
[FC,m7fid mpy 1.herebyfumbhed' GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
Certified copy b filed with the city impection division,
CERTIFICATE OF EXEMPTION FROM WORKERS'. CREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANRARY-STORM G.b10Rf. Date. RCCCI [#
CTBis section need not be completed if the permit to for onahundred dollars
($100)or tem.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Icertify that in the performance ofthe work forwhich this permit is issued,
I shall not employ any Parton In any manner ro u to become subject to the wATERSYsTEm/TREATING
workers Cnmpmxatmn Lawsof Ci(fomia. Date
ZZ Applicant NEW BESIDENTIALPLMB. SQ.Ff. Date - Recei [#
O NOTICE TO APPLICANT-.If,after ma king this Certificate of Exempilon,you
Fshould becomd'
e..bject to the WorkeCompemat Ion provisions of the Labor TOTAL:
0irCode,you must forthwith merply with such provisions or this permit shall be
LU > deemed revoked: BUILDING
dCONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirenthat there Is a construction lending agency for the perform ELECTRIC PEE
Z ance ofthe work for which this permit is Lswed(Sm.3097,Civ.C.), TOTAL;
00 lender'.Name PLUMBING FEE
F Lendee.Addrcss QTY. ;,�_ MECHANICAL•PERMIT' FEE,'
LL - - - MECHANICAL FEE
O W 1md. that Iagrlhave read thlith allcatynand dcoomyordleanceatethat s eInformation
1 ismtoblding complywo,all ndherb muhoriae lnanmandstatslaws 1 PERMIT ISSUANCE FEES PAID:
}
relatingoenterupon t ronsove-mn,anddproprtyorizepectionpurpos of this -
N 'city to enleruponlhe abovomentloned property for inspection purposes AL77920R ADD TO MECH.
? (We)agree to save,mdemNy an d keep harmless the City of Cupertino - Date Receipt#
V against llabllltics,judgments,mks and expenseswitich may In anywayamme AIR HANDLING UNIT 9010,000 CFM) SUBTOTAL:
against said t ncensequ ence of the grant ing of this permit AIR F4ANDW NG UNIT(OVER IO,ODO CFM) CONSTRUCTION TAX
Q CONSTRUCTION TAX PAID:
Signature of�licanl actor Date EXITAUST FLOOD(W/DIIC'D
HAZARDOUS MATERIALS DISCLOSURE
Will tis ppllcant or future building occupant store or handle hazardous HEATING UNIT CTO 100,000 BTU) Date ReceI t
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the I -
Health❑ Yand SafetyCode Sectloon25532(z)? 1 HEATINGUMT(OVPRIDg000BTU) TOTAL
Will the applicantAure building occupant use equipment ordevices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit haanrdom air contaminants..defend by the Bay Area Air
Quality Management District? BOILER-COMP GHPOR 100,000 BTU) P
❑Yea ❑No
Thavc rcadthehazardous materials requirements under Chapter 6.95 of BOILER-COMP(OVL 100,000 RTU) � ' D
the California Health&Safety Code,Sections 25505,25M3 and 25534. I rr.-
underetand that if the building does not currently have a tenant,that it l9 my NEWRESIDENTIALMECI'I. SQ.Fr JUN
�j5 -
responsibility tonotiythe occupantof the requirements which most he met 'IBI KI lag,
prior to issuance of a Certificate of Occupancy. Wsw�
.Cil r v� c
,Owner or authorized agent Data ice. 1SSUEDBY:W V�K1
OFFICE COPY