23757 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification PFIMT NO...
Building Address:
ige
jjV 2375T
caner.1—us: rA` q one: -
V iiia ovvi S /S4/ ^84 1 CITY OF CUPERTINO-BUILDING DIVISION
sono- ora same: Lk.No: APPLICATION / PERMIT aV
IS W BUILDINGELECTRICALPLUMBING-MECHANICAL CATEGORYCONTROL a
Architect/Engineer Lk.No:
QTy ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Thereby affirm that l am licensed under provisions of Chapter 9(mmmenc. APPLIANCES-RESIDENTIAL IPHON
Ingwilh Semon 7000)of Division 3 ofth.Business and Promin onsCode,and my
license la in full force and effect - PANELS
License Clam
Dale CContromtb
actor UP TO 200ANTS
ARCHITECT'S DECLARATION 201-IODDAMPS
cs Zp I understand my plans shall be used as public records OVERIODOAMPS SQ.FT.FLOOR AREA $/SQ.FT.
)y I Fi Licensed Professional SIGNSELECTRICAL
t 6 uuu'S-- OWNER•BNLDER DECLARATION
I'n SPECIAL CIRCUIT/hTLBC
z p, owing r affirsarin.(hat l am 31.5,B fromass a Contractor's License Law for the
qq following reason.(Section 7 m Business and Professions Code:Any city it
� q muntywhkh requlmapermktomrutruR,alter,Impmve,dennllsF,orrepalr ThMP'METER OR POLE INST.
q� 3 any structure prior to its issuance,also requires the applicant for such permit to POWER DEVICES
C5 file a signed statement that he is licensed pursuant to the provisions of the
Q63u,� Contractors License Law(Chapter 9(commencing with Section 7000)of Divi- SWRAWNG POOL ELECTRIC
aion3 ofthe Business and ProfessionsCode)crthat he is exemptthemfromantl VALUATION
O the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSW1C FIXTURES
applicant fora permlt subjedstheapphcantto a dW I pemlty of nae more than
liv�ppndred doll..($500.
t I,as owner of the property, y employees B NEW RESIDENTIAL ELECTR STORIES TYPE CONSTRUCTION
i^n p perty,or m em la ees with wages as their sole �'�' i
compensation,wBldothe work andthestmoture Is not intended or offered for
O sa1e(Sec.700,Businessand Professiow Code:The Contractors Llceme Law
B does not apply to an owner of property who builds or Improves therson,and
who does such work himselforthrough his own employees,provided that such OCC.GROUP RFS UNITS
Improvements are not intended oroffered formic.If,however,the building or TOTAL:
Improvement iss.ld within one yearofoompletion,the owner-bu0derw111 have
the burden of proving that he did not,build or Improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
u L as owner of the property,am exclusively contracting with licensed PFRMLL ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractor's License Law does not apply to an..at of property who ALTER-DRAIN&VENT-WATER(EA)
builds or Improves thereon,and who contra for such ptojeRs with a
co,,LtdtTTactoKe)licensed p...antt.th.Contractor's Lkenae Law. FEE SUMMARY
LJ I am exempt under See. B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
. Owner Date ftfCEB'I R
WORKMAN COMPENSATION DECLARATION IV(.IVRES PEIi.l72AP SCHOOL TAX Y_ N
QI hereby af(Irm that I have a certiBcete of consent to self-Insure,ora RECEIPT M
cenificateofWorken'Compessadonlrsurancemamnifledmpythereof(Sec.
3800,Lab C.) S F.A.GASYSTEM-1 INCAOUTLETS PARK FEE Y N
Pollry b RKEE'C
Comny CAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION
ISION FEES� rt1(led
copy Is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy V filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CRE-APSE TRAP PAID
COMPENSATION INSURANCE BEINE&$AMTAAY-SNItM EA 2WFI. Date Recei tq
(This section need not be completed lithe permit 6 ionone hundred dollars
($10(Borless.) ATER TQt w/venin/EI.ECTR ENERGYFEE Y N
I certify that In the performance of the work for which this permit is issued,
I shall not employ any person In any manner an as to become sub)mt to the WATPR SYSTEM/TREATING
Wmkem'Compens tion Law.of California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQFI. Date Recei tIf
ZO NOTICEco esubjet totheaorks.'fter omensationng this ipuwixark ofcate of
Labor
should become subject to the Workers'Compensation provlais p of the Lobar TOTAL:
� N Code,ynavokefwthwith comply with mchprovkioro..thin permit shall be BUILDING E
W y deemedrevoked.
a CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Ihereby affirm that there is a construction lending agency for the perfortm ELECTRIC FEE
Z ante ofthe work forwhtch this permit is Issued(Sec.3097,Civ.C.) TO ��
V O Lenders Name PLUMBING FEE
1L F Lendce.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I mdlfythatl have readthisapplicetionard statethatfheZ ve Information
is correct.l agree to comply withal city and counlyordinances and state laws PERMITISSUANCE FEES PAID:
} N ereze relating to building construction,and hereby authorirepresentative.ofthls
r Z cityto enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH. - Date Recei tN
(We)agree to save,Indemnify an d keep harmless the City of Cupertino P
against llkniltics,ydgramts,mks and expenses which may in anywayammeAIR HANDLING UNIT(TO 10,D00 CFM) SUBTOTAL'
agai said In con aeon o(th granting of this permit '
//�=3C/►/ t AIR HANDLING UNIT(OVER 10,0oocPM1 CONSTRUCTION TAX
CO 6-I-9Z , CONSTRUCTION TAX PAID:
Signat of Applicant/Conractor Date EXHAUST HOOD(W/DUCT[
HAZARDOUS MATE SDISCLOSURE
Will the applicant or future budding occupant store or handle hazardous HEATING UNIT(TO 100,000 BTT) Date Recei tri
material as defined by the Cupertino Municipal Cade,Chapter 9.12,and the
Health and Safely Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU), TOTAL
Yes M No
Will the applicant orfuture building occupant use equipments devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
lity Management District? BORER-COMP DHP OR 100,000 BTU) B9 ar p�
. ave Yes M❑us Y {� ' L7
shave read the hazardous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000BN)
the California Health&Safety Code,Sections 25505,25533 and 25534. I
undrespntandthat if the notify
the ing doesoccupant of to requirmhave swhich.that b mots my NEWRESIDENTIAL MECH. SQ.Ff JU `1 1992
r rnpoto isaulyto of a Cedi occupant=pancqulrements which must be oat
prior to Issuance of a Certificate of Ompanry. C!+r
--- Wr
Owner....thorised a gent Date' - ISSUED BY: GUr�`
TOTAL:
\ OFFICE COPY