23223 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification — PERMITNO.
Building AQ7-2—" snzVp� 2
3223
ne . ameh
P_fL��' •F rS j[) CITY OF CUPERTINO-BUILDING DIVISION
LIc.No: APPLICATION / PERMITAbe \
' -[�r1 0 BUILDING-ELECTRICALPLUMB GMECHANICAL CATEGORY CON'Qlbe
uct/Englneer•. 1 Lie No: (7 �
Ma
1,L1-144 1 11 ti, BUILDING PERMIT INFO
QTY ELECTRI ERMIT FEE
Address: - I'ERhRTISSIJANCE T• Sj 1
LICENSED CONTRACTOR'S DECLARATION LYY L.�Y
Ihercectionby rmthat)mDh,Rcensedue under Bu provblanaol Chapter 9(rommrnc APPLIANCES D L JOB OPSCREaHON
It...ISection 7000)afd offiret. afthe Bug sand Pm(enslaneCode,and my -A—t"
-,a t �
license la I-(u-u effatt- (7 I — PANELS L�v w
ec LIc Y O I.a
ate Contractor
ARCHITECT'S DECLARATION Lba20IIAMAMPS
q�q�++N CCZ l understand my plana shall be used as public records. OVER 1000 AM SQ.FT.FLOOR AREA S/SQ.FT.
k'() Licensed Pmfeselavl CNSEL AL fl O
�<<< OWNER-BUILDER DECLARATION NT LSC 'L T
2s' a Ihereby.fil.that l am exempt from the Contractors License t
qqqqqq following reason.(Section 7071.5,Business and Professions Code:Anyci
roc my which requiresa permit to com uct,alter,Improve,demollsh,orrcpalr _
'� 1ETIR POLE INSf.
qany structure prior to lb issuance,also requires the applicant for such permit to
F 1,1<6 file a signed statement that he Is licensed pursuant to the provisions of the D ES—
W6iSaOt�, Contnamr'e Lkcrue Law(Chapter9(commencing with 5ect1on 7W0)o(Divl- SWIMMING POOL ELECTRIC
elon3 ofthe Bueinessand ProfessimatCode)mthat he is exempt therefromand VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any a�/S /J L^
< appliant for a permit subjects the applicant to a civil penalty of net exam t ban UTLE7'SSWITCHESEKTURFS Z/ s+1I i/KI�J)
live hundred dollars(S.AW.
�n ❑I,as owner of the property, NEW RESIDENTIAL ELECTRSQFr. STORIES TYPECONSTRUCTION
p wk a or he employees with wages a thele door
C
compensation,lingwill thework+ndthegrace Code:e Is not TheConttendedoicanced for
Law
+O oak(Sec.7094 Realness and l'rofessioru Code:The Contractors Llcerue Law
q3 does notapply loan ower of property who build+or improves thereon,and -Oki A
whedees suchwork himself orthrough hlsownemployees,provided that each
IceProvementsama intendMorofferedforeale.ILhewevepthebulldingor TOT)L ® (� Q
Improvement issold withmoneyearofcomplation,the owner-bullderwlli have
tryyLa en of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOODZt
Lt 4 as owner of the property,am exclusively contracting with licensed .7
contractors to construct the project(Sac.7014,Business arta Professions Code: PERMIT ISSUANCE ATE
The Contractors Lures law does not apply to anowner of property who ALTER-DRAINk VENT-WATER(EA)
beillds or leap.thereon, and who contram for such p7ojem whh a
crn.dor(e)licensed pursuant m the Contractors Liceme Law, FEE SUMMARY
LJ
land
am exempt under Sec B h P C for this reason BACK FLAW PROTECT.DEVICE
Owner Date
DRAI NS FLOOR ROOF,AREA,COND, SANITARY Y_ N-
WORK MAN COMPENSATION DECLARATION RECEPTFIXTURES PER TRAP �. SCHOOL TAX Y— N_
I hereby affirm that 1 have a certiflata of consent to eel(-Insure,or RECEIPT M
cedifcade of Workrri Compensation Insurance or a certlfled ropy thereof(Sec. 42GAS,EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N_
3800,Lab C.) �! rat
Policy — _ GAS FA.SYSTIM-OVER 4(EA) RECBUILDING DIVISION FEES
�Cn v
edified copy b herebyfurnished.the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHEC
Certlfled copy ls filed with the city Inspection division. VV
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP P[1f1
COMPENSATION INSURANCE SEWER- STORM-STORM EA.2flOFf. `\--0- a Be
(TFlssenbn need net be completed tithe permit later one hundred dollars
(St Icartiiess.) WATER HEATER W/VENT/ELECTR ENE 'E Y
Ill em employt in
anpersonIPerformance any
exasserhe so as to b co pesubjecrmit I.blued,
I shall not employ any person In any manner n u to become subject to the WATER SYSIII.//TREATING
Worked Compenutlon Gws o/UII(omh.
Data PA
O Z NOTICApplicaE
NEWREMDENTiALPLMB. SQPr Date
-Z0 NOTICE TOAPPLICANT:othL ori cot-Comaldna hb Certificate Iiof omopteLabd
ahold become subject to the Workers'Comperwtlon provlvlom of the Labor TOTAL'
Ir
N Cade,you must forthwith comply with such provlelord orthis permit shall D N
deemed revoked. '
W
0 CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyao rwhichtbut there has romit is timtIssu lendingagrnq for the perform- /� ,�� �J ELECTRIC FEE
Z anro ofthe work(arwhkhthls permitbbwed(Sec.3097,CIv.CJ Y..t.Q'{ y4 T
V O Lender's Name PLUMBING FEE
IL F LandereAdd. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U 1cedlfythatl have read thbappllationand state thattheabove Information
O W is correct.I agree to complywithall cityand county ordinances and elate laws PERMITISSUANCE � FEES PAID:
IL relating to building construction,and hereby authodea representatives ofthle
r N city to enter upon the abovnmentloned property for inspection purposes, ALTER ORADDTO MECH. �.
? (We)agree to save,indemnify an d keep harmless the City of Cupertino Date ReceiptM
I..Y agaimt liabWties,}idgmenta,routs and expenses which my In anywayaceree AIR HANDLING UNIT CFO FLOM CFM) SUBTOTAL:
agairutaxi ,I nconsequenwofthe ntln of th pr Ip
4'3,9 AIR HANDLING UNIT(OVER IQOOOCFM) CONSTRUCTION TAX
S e te—(Applicant/Contractor Date IXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS U LOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,0008TU) Date Recei
material as defined by the Cupertino Municipal Code,Chapter 91Z and the
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,(100 BTI) TO
Fly. u No
Will the applicant or future building oavpart use equipment or devices VPN17LATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air ronuminanta as defined by the Bay Area Air
Quality Management District? BO[LER-COMP OHPOR 100,OM BTU) p p oT
na Yea n❑No A I
'l have read the hazardous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
e California Health ASo(cry Code,Beet lore 75505,25513 and 25534.1 ('/r,, o
1 understarad that if the building docs not currently have a here at,that it le my NEW RESIDENTIAL MECIi. SQ.FT V\/IU 3 1992
responsibility to not lfy the occupant of the requirements wh lch must be met v
prioriolssuanceofaUdifiateofOmupancy. CITY Uf Lul
V thlffyL
Owner or authotlud a gent Data /e ISSUEDBY:
TOT
OFFICE COPY