21392 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
_Building Project Identification PER.WT NO.
290a:llul000fbyr br 2
13 9 2
rare one: A IE
r.QMss .Todd 96- A2P'/6 CITY OF CUPERTINO-BUILDING DIVISION 2Z q
Cont or°Name: APPLICATION I PERMIT
Ci LI9.N°:ea' BUILDING-ELECTRICALPLUMBINGMECFUMCAL CATEGORY CONTROL N
Architect/En er. Llc.N. C
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add.,. PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I Mrcby.afibm that l am Bernaed under prwisons of Chapter 9(cerement, APPLIANCES-RESIDENTIAL JOB DFSCRII'170N
mgwith SA&km 7000)of Division3 oflhe Buslnessand Pro(essionsCede,and my
lfrenee is m mu fo .na err«.. C� PAN
0 ,p�,lTfl Yl
Date Clap V Lk.Y • ��
Date }�9f Contraao ��p
ARCHITECT WRc rAr )(VER 10AMI'S
pQ±reO Zp Iunderstend my plans shall used vpubhcmroras OVER 1000 AMPS SQ.Fr.FLOOR AREA L5/SQ.FT.
E censed Professional SIGNS ELECTRICAL
Li
666"' OWNERBUILDER DECLARATION ^ 1 ^ �-Y
7� rc
a Ihebya(Orm that]eco exempt Contractor's fromthe ContContractor's Lirense laSPECIALCIRCUIT/MISC w forthe aC.l L•� ��t C
oo following reason.F, (ScaHon 7071.5,Business and Profmbna Code:Any city or I"ty c°untywhichrequimaper ttommimct,alter,lmpmve,dem lish,ormpalr TEMP'METER OR POLE INST.
anystructum prior/o,its issuance,alsorequlrestheapplinnl(crouch permit to POWER DEVICES
ills a signed statement that he is Ilccnsed pursuant to the provislom of the
GµL. Contractor's License Law(Chapter 9(commencing with Section 7000)of DWI- SWIMMING POOL ELECTRIC
Flb
sien 3 ofthe Business and Professions Code)or that he iseaempt thcrc7 fromand
the basis for the alleged exemption. Any violation of Seerkn 7071.5 by any S OUTLETS—SWITCHES-FIXTURES l ' /..� ^,J 2. �
O appBrant fon perMbub)ectslhe applicant taacivll perulty Wnot mort than t VALUATION
l v
five hundred dolkrs(IS00. - NEW RESIDENTIAL ELECTR gQ,FT. STORIES 7YPECONSIRIK170N
comp
I«7 6 I,as owner of the property,or my employees with wages as their sole
compensation willdothe work and the structure is not intended or offered for
��q sale(Sec.7044,Business and Pmfe®lora Code:TM Cont.does License law
�j $
does not apply to an owner of property who builds or improves thereon,and
µ who does such work himself orthrough his own employees,provided that such OCC.GROUP RES.UMTS
improvements are not Intended or offered for sale.If,however,the build Ing or TOTAL: 1
improvement issold withinoneyearofcompleliogtheowner-bullderwill have
the burden of proving that he did not build or improve for purpose of sale). QTY, PLUMBING PERMIT FEE FLOOD WNE APN
M I,as owner of the property,am exclusively contracting with licensed
contractors to consumer the projeci(Sec.7014 Bush.and Protmbns Cade: PPRMITLSSUANCE l�sit
The Contractors Liernse Law does not apply to an owner of pmperty who ALTER-DRAIN&VENT-WATER(PA) ll.-s W
builds or Improves thereon,and who contracts for such p(ojecis with a " FEE SUMMARY
maJpaor(s)Bmnsed pursuant to the Comrer
aore License Law. BACK FLOW PROTECT.DEVICE
LI I am exempt under Sec B k P C for this reawn
•
Owner Date
DRAINS R A,COND.FLOOR ROOF,ARESANITARY Y N aOPKMAN COMPENSATION DECLARATION RECEIPT I
❑ (Q(�D SCI
I hereby affirm that I have a certificate of consent to self-inFIXTURES PER TRAP TOOLTAX Y N
sure,or RFGEB'I'X
certificate of Workers'Compematlonleaurance cep a certified copy thereef(Sec. GAS EA SYSTEM-1 INC4 OUTLETS �� PARK FEE Y N
3800,leis C) r7/ //�,7'� /D RECEIPT Pollry M �7
Cmand a GAS.EA,SYSTEM-OVER d(PA)
BUILDING DIVISION FEES
Certified copy is hereby furnished. CREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy is filed withh the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 20GFT Date Recel N1 ,
(Tan need eat completed i(the permit is tu(arohundred dollars
(SIM)MI.) I WATER HEATER W/VENT/EIRCT.R '�s� ENERGY FEE Y N
(certifyifythat
he that In the performance of the work for which this permit is issued, l
I shall not employ any perms In any manner at ae to become ubjeer to the WATER SYSTGI/TREATING
Workcm't employ anon Laws of Calll Maur Date PAID �- Q
Z Z NOT( NEW,RESIDENTIAL PLMB. SQXT. Date Remi tfi
0 NOliant
Applicant
APPLICANT;If,after nuking this Certlfkate or Exemption,you
should become subject to the Wmken'Comp MAatlon provisions of the Labor TOTAL: 4
N
Code,you muotfort hwith comply with such provisiom or th is perMtshall be D
> deemed revoked. '
W
C CONSTRUCTION LENDING AGENCY SEISMICFEE IO
I hereby affirm that there is a construction lending agency for the perform- ELECTRIC FEE
M Z ance of the work for which this permit is hated(Ser.30W,Civ.C.) TOTAL: W 4
00 I<nd=r'e Name PLUMBING FEE Ow
U. I- Lender's Addresa QTY.I MECHANICAL PERMIT FEE MECHANICAL FEE `as
O W Icenwatl
lfythatl have read thisapplication and statethattheabelnformon
a bmnect.I dgrceto comply with all city and county ordinances andstatelaws PERMIT ISSUANCE ��a FEESPAID
} relating to building construction,and hereby authorize representatives otthla 11 a,��
F 2 city to enter upon the abovo-mentbned property for Inspection purposes. ,Ip ALTER OR ADD TO MOCK sW Dale Recei IN
— (We)agree to save,Indemnity an d keep harmless the City of Cupertino
A lost it. jB e,)ud meet costs d opensee whichmayinanywayaccrue AIR HANDU NO UNIT DO 10,000 CPM) SUBTOTAL:
A ala ts m sere - log of this permit AIR HANDLING UNIT(OVER 10,030 CFM) CONSTRUCTION TAX
re pplicant/Contractor -" Dat EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA ZAR DOU ATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
material as defined by the Cu pedino Municipal Code,Chapter 9.12,and the _ Date ReceI IM
I ealth a nd Safety C ciion 75532(a)I HEATING UNIT(OVER 100,000 HIM TOTALkIll,It bO
rl Yea No _
111 the Applicantr(uturc building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) DATE
which emit harardous air contaminants as defined by the Bay Area Air
Quality Management QjlltpIci7 BORER.COMP(31IPOR 100,000 BTU) �ds�
4 Yes No A Ys j
havcread Healthe h
Safety
Code,ls Sections
2ments5333 and
of BOILER-COMP(OV[R 1W,000 BTU) f( a �
the Calunderstand
t health k d Code,Sot Curr 75505,have
a t and 25534.I
understand that lfthc buildingdces not currently havoatenant,that itismy NEW RESIDENTIAL MF.CH. SQ.FT. /llOa.M�1�
I rulbilityt only the occupant of the requirements which must be met s�HH�a K4 s17
io a e a ficatcor0ccupancy.
C aE9 2�Quxf2
ranuthorlred t Dale ISSUED
O aa.IIV TOTAh.
OFFICE COPY