21650 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro ect Identification .. PERMITNO.
Building Address: )) �7 /�a3 O
Jo� �f Sa 3/4N / 27 -75/ :z- -.z, G I 5
nere sore: one, APPLICATION A
A, a . CITY OF CUPERTINO-BUILDING DIVISION
Lic.Nu. APPLICATION /PERMIT
'
cmo-ada ani,C
39 7 BUILDING-ELECTRICALPLUMBING-MFcFiAMCAL CATFC.ORY CONTROL it
Archiled/_�gineer. - Lk.No: "
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
AddressPERMITISSUANCE dJ 1'NTI �
LICENSED CONTRACTOR'S DECLARATION T LSI �LJ
thereby aflUmthat l son Licensed under provisions of Chapter9(commmc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwlta5ection70rmand effem3ofthe Bu.inessand Profes.lonsCode,and my ��S
bce In fuB roe and died. PANELS
rensrcl,a. Cont 39tS9�f'7
Date Cantnctor LIF TO 2DO AMES
ARCHITECT'S DECLARATION 201-1W0 AMPS
I understand my platy shall be used u public records. OVER 1000 AMPS .FI.FLOOR AREA - E/SQ.FT.
C "
(1 Licensed Profenlowl SIGNS ELECTRICAL '
'c Fd OWNER-BUILDER DECLARATION SPECIAL CIltCUfT/MISC
zF'�& I hereby affirmtaatIamexempt from the Contractor's License Law for the -
following reason.(Section 7101.5,Business and Professions Code:Any city or
F t countywhichmqubesa Pen ttocmutmc"ter,improve,de=lWh,orrepair T'�P.ME[ERORPOLEINST.
q'� anystmdure prior to its Issuance,also requires the applicant for such permit to
PJ O
ilk a signed statement that he is licensed pursuant to the provisions of the EWER DEVICES
W6.3p� Contractor's License Law(Chapter 9(commencing with Section 70W)of Divi. gyylMhENGIWLELECIRIC
H sion3ofthe Businessand ProfesslormCode)arthathelsexempttherefromand VALUATION
the basis for the alleged exemption. Any violation of Section 70315 by an a f� L/
« appllant fora permit subjectsthe applicant to a civil penalty of not more the OUME7SSWITCHESFIXTURES vC`•E
five hundred dollars($50%.
I,as owner of the property,or my employees with wages as their sok NEW RESIDENTIAL ITT
__SQ.FT. STORIES TYPE CONSTRUCTION
compensation,will do the work and the structure is not Intended or offeredfor
O sale(Sec.7044,Business and Professions Cade:The Contractor's License Law
does not apply to an owner of property who builds or improves thereon,and
OCC.GROUP RFS UNITS
who does suchwork hu selforthrough his own employees,provided that such
Improvements are not intended oroffered forale.It however,thebullding or TOTAL:
Improvement Issold within oneyearo(completlom the owner-builderwlll have
KOO
t, den of proving that he did not bund or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FTpp DONNE
Mr asas owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractors License taw does not apply to an owner of property who
'.Wild'. or Improves thereon,and who--tracts for such projects with
ALTII4�DRAIN k VFM-WATER(EA)
cgp(�acYm(9)Licensed pursuant to the Contradoes License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
Ll l am exempt under Sec. B 6 P C for this reason
DRAINS FLOOR ROOF,AREA,CONE). SANITARY Y_ N_
Owner Date RECEB'F p
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y— N_
QI hereby affirm that t have a mKificatlmume of consent d self-insure,pythemof ora RECEIPT a
certiflab of Workers Comperwtlonlmurancemacertifled eopythereo((Seo. GAS EA.BYSfEM-1 INCA OUTLETS '� PARK FEE y N
Polis380D,Lab CJ
Policyp RECEIDING DIVISION
_
Com an GAS EA.SYSTEM-0OVER Y - BUILDING DIVISION FEES
�Cadifled copy I,herebyth the city GREASEANDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
�Cerilfied copyls(ikd with the city inspection division.
CERTIFICATE OF UMPI'ION FROM WORKERS' GREASE TRAP PAID
r COMPENSATION INSURANCE SEWER-SANITARY-STORM FA 200F1' Date Recei t#
(T)m Icxxlon need na be completed if the permit ls(orone hundred dollars
($1 I0)otifythin WATER HEATER W/VENT/ELFCTR ENERGY FEE Y ,N
(certify that employ
anpersoniperformance anof y
mannerhe so as to b co peeNt ls issued, —
I shag not empky any person In any manner as u to become subject to the WATER SYSTEM/TREATING
Workers'CompensaHon Laws of GLifomla.Date PAID '
O Z Applicant NEW RESIDENTIAL ELMS. SQ.Ff. Date Recel t#
Z 0 NOlicant APPLICANT-.If,after making this CertBlate o(Fxemptlan,you
shouldb,mresubject to the Workers'Compenaion provisions ofthe Labor TOTAL:
L
Code,you must forthwith comply with such provisions orthis permit shall be NG, Q
y deemed revoked. FEE
LU
CONSTRUCTION LENDING AGENCY SEISMIC FEE
Ihfthew Brmthat them lsacomitisisued(Slending agency for.) perform- TOFAL: ELECTRIC FEE l�
:MZ once o(theworkforwhkhthis permitlslsaued(Sec.3097,CIv.CJ � s��
0 O Lender'.Name PLUMBING FEE - ow
LL f Looderb Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE ,r.asan
O W Icon Uythatl have reaithis application and statethattheaboveleformatlm s+la//
ls correct.Iagreeto comply with all city county and date laws PERMIT ISSUANCE 1'2—67 FEES PAID:
IL rektingtobuildingmnstrudloM and herebyauthomm representativeso(this
2 city to enterupon the abovcmentioned property for inspection purposes. ALTER OR ADD TO MECH. Date R2Ce1 f#
— (We)agree to save,Indemnify an d keep harmless the City of Cu pertbw p
against Bab Lities,jIdgmenh,rortsand expenses which may in anywayamme AIR HANDLING UNIT ITO To,"CFM) SUBTOTAL:
agamuts City incone a ofthe grantiv Mthls permit.
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Signa of Applicant/Contractor Date IXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theappllcant orhiwm building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Reeei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
_ Health and Safety Code Section 25532(.)7 HEATING UNIT(OVER 100,000 BTU) ALt t
Yes �]No - ,_
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISS ATE
which emit haaardom air contaminants as defined by the Bay Area Air p�
Quality Management District? BORER-COMP QHP OR 100,IXq BTU)
4 Yes gNo ��
have read the baza ous materials requirements under Chapter 6,95 of BOILER-COMP(OVER 100,000 BTU)
the California Health k Safety Code,Sections 75505,25533 and 25534.I
understand that lithe building does not amently have a tenant,that it is my NEW RESIDENTIAL MECH. SQFT.
responsibility to notify the occupant of the requirements which must be met
prior to Issuance of a Certificate of Ocapa ocy.
Owner or autharlud agent Date ISSUEDBYY_sZE���
TOTAL: a W
OFFICE COPY.