24111 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PF]LWTNQ, 41;11
Building dddmss:
e � -
neraName: one: APPLICATION SUBMITIALy
(34g Limo C" CITY OF CUPERTINO-BUILDING DIVISION
C jVado aIN &177&K/y/Lic.No: APPLICATION / PERMIT
Ry a r+''/!b BUILDING-ELECnUCALPLUMBINGMECHAMCAL CATEGORY CONTROL
Archilett/Engin Uc.No:
.V BUILDING PERMIT INFO
T-7� QTY ELECTRIC PERMIT FEE
Address: Z)r pt PERMITISSUANCE r.Q' E] 1:1LICENSED CONTRACTOR'S DECLARATI pp���
I hereby affirm that l am licensed under provisions ofC btr�j ft!e APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwith Semon 7000).!Dh,W.n3ofthe Bualnessand ProfnsionCode,and my
I= la in(ullb effect 1774( PANEIS
Lion C CL Lk.N, ! t
Date Contractor \.
ARCHITECTS DECLARATI 201-IODO AMPS
o4° Tunderstand myphnshaBbe used aspubheremrds. OVERIODOAMPS SQ.FT. AREA $/SQ.FT.
L. ED IN
Licensed Professional SIGNS ELECTRICAL
Q OWNER-BUILDER DECLARATION P T R
In SP[CIAL CIl2CNT/MLSC
Thereby affirm that lam exempt from the Contractor's License Law for the
following reason.(Section 7071.5,Business and Professions Code:Any city or
ocounTEMP.MLIIIt OR POLE INST. 2i
j.
anystm mrequiteapermitemnnquialley,Improve,demrsuch, er ttr S(,(
file signed
statement
WuavIs lice re d pursuant to the rtwisi es of tt a IyOWER DEVICES T
(Ile a signed statement that he tr licensed pursuant t.the provision of the
�u•� Contractors Llcemue Law(Chapter 9(commencing with Section 7WO)of Divl- SWIMMING POOL ELECTRIC VALUATION
O< sion3ofthe Buslnemand Profession Cde)orthat hebeum themfromand
Q? the basis for the alleged exemption. Any violation of Section 7011.5 by any OUTLETSSSWITCHESFIX'TURES �j•O /R
applicant far.peractsubm
jects the applicant to a civil penalty of not ore than !.-S l/
c, five hundred dollars($500). NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPECONSTRUCTION
MI,as owner of the property,or my employees with wages as their sole
k/Q rompenation,wBldoth.adl Pr ndthesCde:TbC.at.c.a oroffemUw
❑ sale(Sec.apply
to alnowand Profession Code:The Contractor.Lkeon Law
docsoatapply work ownerofproperty who Wilds loimprovetedthatand OCC.GROUP RES.UNITS
FS^ whodoementsasuch am not
msenedorongh fferedowne.If,hon, er,thedthatsuch
improvements intendd.tufferompleffor le the uwevegtheerwill nae TOTAL: D V
Improvement bwird proving that M did not Wild
fin the a for prose of sale.).
thLj 1,as weerof the p he did not exclusively
orvely con for oath licensed
QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
u I,as sneer of the property,am.7044,vely retracting with esCod PERMIT ISSUANCE
The
(Sec.apply
to
Profession Code:
The Cont impr'a License law don nhe apply tct, f owner I property,who
Wild..r Improve thereon, and who wnvary (.r such plojeM with a ALTER-DRAW&VEM-WATER(EA)
c9fitfactor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LI I am exempt under Sec. B h P C for this masonOUTSIDLITES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
. Owner Date RECEIPT p
WORK MAN COMPENSATION DECLARATION FlX'IVRFS PER TRAP SCHOOLTAX Y_ N_
[� by affirm the I have a certificate of consent mself-inwrc,ora RECEIPT N
certificate.fWorkers'Comper^wJtlonlln/urance as certified mpythemof(Sec. GAS EA.SYSI'EM-1 INCA OUTLETS PARK I•g Y_ N_
3800,La %/�/z7 DING DIN
PoliryN �-- � CAS EA.SYSTGI-0VFR4(EA) BUILDING DI VISION FF.IiS
Com sena
�Cenmd ropy ehereby rn a d. PLANCHECK FEE
$Wro Ufied ropy Is filed with the city W T
Inspection division. GREASE RAP RL WASTE INTERCEPTOR'^5 CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER.SANRARY-STORM EA 200FI Date Remi I#
(This sectiond Nenet M completed if the permit V for ane hundrd dollars
($100).,less.) WATER HEATER W/VEM/F1,ECTR ENERGYFEE Y_ N_
I a rtifythat in the performance of Ne work for which this permit la Issued,
I shall not employ any person in any manner so as to became subject to theWATER SYS7T]d/.IAEA.I7NG
Worka Compensation laws of California. Date PAID
OZ Applicant NEW RESIDENTIAL PCMB. SQFf. Date Remi t#
Z O NOTICE TO APPLICANMILaNer making this Certificate of Emnaption,you
should berme subject to the Workers'Compematlon provision of the Labor TOTAL:
(J) Cde,you must forthwith comply with each provision orthb permit&hall he BUILDING FEE •O
IL Gmdeeed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL IherebyaffIrmthat there is acontruction lencilegagency forthe perform TOTAL: ELECTRIC FEE 47.0
7 Z a are of the work for which this permit is issued(Ser.3097,Civ.C.) PLUMBING FEE
U O Leadeea Nara
LL h- Lenders Addmaa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U Icertifythat l havereadthb applicationad sarathat the above Information
O W Incorrect.7 agree to comply with all city and county ordinances and state laws PERMITISSUANCE FEES PAID:
0. relating lobullding construction,and herby authorize representatives of this
F % city to enter upon the above-mentlond property fa Wpectionpurposes. ALTERORADDTOMECH.
? (We)agree to nave,indemmdfy and keep harmless the City of Cupertino Date Receipt#
V against liabilities,joy eta,mob and Nraus which may in any wayaaxue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: f
q int aaaaaam City i egaemre grannng.nni.permit CONSTRUCTION TAX
rJ / //9f/yhQe AIRHANDLINGUMT(OVERIO,OWCIM)
gnaQ o! ppgceaaor _ V Date EXHAUST HOOD(W/DIK'D CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a ppllcant or future building occv pant store or handle hazardous HEATING UNIT(TO 100,000 BTT) Date Recel t#
material as defined by the Cupertino Municipal Cde,Chapter 93Z ad the HEATING UNIT 100,000 BTI!)
Health and Safety Cd ctlm 2S532(a)7 TOTAL:
Yrs INo
Will the applicant or(u arc building occupant use equipment or devices VENDLATION FAN(SINGLE RESID) ISSUANCE DATE
which emit harardous air contaminants as defined by the Bay Area Air - pq Y
Quality Management m R7 BOILER-COMP DHP OR 100,000 BTU)
4Yes o�
have r is I le.th& t teriab reons 255 5,2553 Band2S5Chapter 6,95 of BOILER-COMP(OVER 100,000 BN) AUG 181992
the
erstadteat ifthbSafetyCde,Sections 25505,25533 a t ands,that I
understand that if the building does not evrrcntly have alenant,that itbmy NEW RTSIDFN77AI.MECFI. SQ.FF
responsibility to notify th pant of themquttorments which must be met
7 pdortoissuance.face 'ate of panty. ^�/e � CilY l/r vc/re(il tivU
7Vr V '
Owner or aulhorizcd agent Date TOTAL: ISSUEDBAJ_
OFFICE COPY