20892 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building project Identification PERMITNO.-
BuildingAddree: /�0^�'t89 G f'
/O /9S' - 'R&-S&W i 4,+Ao CQAD7e,�—x"c G
,,are one;
/�'//Cf'{NQ rL. Loi ocn CITY OF CUPERTIINOIIUILDING DIVISION
Contra r' "• Ll "g APPLICATION I PERMIT
9�P-359/
Architect/Engineer. Lie No. BUILDING-ELECTRICALI'LUMBINGMECFIAMCAL CATEGORY CO
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addmc 1 PERMITISSUANCEY' IK-1' I�Y
LICENSED CONTRACTOR'S DECLARATION wx L0 �'{
Iherebyefflrm that l amllcensed under provisions of Chapter9(mmmenc APPLIANCES.RESMENTIALeDFSCRBrfLON
ingwllh SeRlon7000)of Dlvisidn3otthe Bumineesand ProfeealoneCode,end my p ryT�S
Ilcense la In full(coos and effect PANELS RF p--'"' _
License Cse Ls.N
Date Lic.# or
ARCHITECTS DECLARATION 201-IODOAMPS
pQ+X7 I understand my plain shall be used ea public records OVERIOOOAMP$ SQ.FT.
E d E Licensed Professional SIGNS ELECTRICAL A
<«<�6 k! - OWNER-BUILDER DECLARATION SPECHALCIRCU1T/ML9C (JD /
71..,�7a There byaf0rmthat l am exempt fromthe Contractor's License taw for the A
o q following recon.(Section 7CO S,Buelnee and Pmfoad ..Code:Anct or
FunU'§ extetywhich mquiraa perndleoconsnmct,alter,Improve,demollah,orrepalr TEMP.MEIIRORPOLEINST.
'-1 any structure pdortoltsissuance,alsorequires theapplicamfm such permit to POWER DEVICES
file a signed statement that he is licensed pursuant to the provisions of the
Ow Contractors License Law(Chapter 9(commencing with Section 7000)ofDivi-
�OJ tlon3ofsln
the BueseendPmf.IomCs
ode)mthM he exempttherefromand SWIMMING IDOL ELECTRIC rN-� V ON
0....7777 the bass for the alleged exemption. Any violetlgn gf Section 7031S by any d OUILETSSWITCHESFIXITJIiFS (� ` ��•-
appBceeffect J Q�
five tired tiglians(5500). NEW RESIDENTIAL ELECTRSQPT STORIES TYPE CONSTRUCTION
�n ars owner of the property,or my employee with wages a there sok
c mpeneaHon,goal. t.e work.andthes Code: ist he c.nteeded or offered for
q le(Sec.7sm ply to alnowandf property
Code:The Contractor's License Law
doeuessuchorn owner of through
thatend OCC.GROUP RFS.UNITS
CC.. whod0em,mis are not mself or edorwghhsownIf,hememployees, arothe build
ing or much ^ 00
improvcmentenold Intended earofred pletor io.tf, mvme p llder llt have TOTAL: 4
Improvement scold within one yearofcomplctiory the ownervbullderwlli have
OW-llurden of proving that he did cot build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE
u L as owner of the property,am exclusively contracting with licensed FLOOD ZONE APN
contractors to construct the project(Sm 70K Business and Profeasions Code: ( PERMIT ISSUANCE c�
The Contractor's License taw doe not apply to an owner of property who l.A+
Wilds or Improver thereon,and who contracts for much Injects with a ALTER-DRAIN&VENT-WATER(EA)
m�((aeorp)licensed puns...to the Contractor's Llmme Law. FEE SUMMARY
_ l._I I am exempt under Sec B&P C for this reason BACK FLOW PROTECT.DEVICE
OUTSIDEFEES
GRAINS FLOOR ROOF,ARBA,COND. SANITARY Y_ N_
Owner Date RECEB'T N
WORKMAN COMPENSATION DECLARATION FIXNRFS PER.IRAP SCHOOLTAX Y_ N
of hereby affirm that I have a dertlMale at consent to self-Inure,or �re RECEIPT N
3800,LabC)omificate Workeri Compensatlgn Insurance ore certl(kd copy thereof(Sec. GAS EA.SYSIE.1-1INCA OUILETS 2tw PARK FEE Y N_
Policy N RECEIPT N
GAS EA.SYSTEM-OVER 4(EA)
Com any - BUILDING DIVISION FEES
[
Cer+Ned copy s hereby tumshed. GRFASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
�CertBled copylas Ned with the city Inspection division. Q]� /,�,��
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID (/I t�}jII
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA,200FT. Dale Recei t—#
(Thissection need not be completed B the permit is(mom hundred dollars
(El")orfese,) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certify thatInChep person
in nymwork for which to
mubd tweed,
I shag not employ any perws In any manner w u to become ubjett to the WATEt.SYSTEM/TREATING Workem'Compeosatign lawn of California. Date PAID
-
Z Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
Z O NOTICETO APPLICANT:If,after making this Cartltlate of Exemption,you
should become ubjecl to the Workers'Compensation pmvslons of the Labor - TOTAL:
CCN, Code,you must forthwith comply with much provisions orths permit shall be BUILDING FEEl�
LU j deamed revoked.
CONSTRUCTION LENDING AGENCY �} �qfs SEISMIC FEE 150
a Ihercbyrorkfor tthem sacomiin Issuioned
ld(See.ag7,Civ, .) peAorm- - TOTAL I—h ELECTRICFEE '1LCO
u Z ance the work for which the permit sblued(Sec.3097,Civ,C.) l.Y
(� O Iander'•Name PLUMBING FEE e.l,I C13
LL F Lenders Addree QTY. MECHANICAL PERMIT FEE MECHANICAL FEE 00
O W Icertlfy that l have read this applleation and state that the above Information
4 srelcoingt building complywith all ndherand mu eby urate representatives
and Matelaws PEIiMITISSUANCE 2x(30 F' $ D� y st
} cityt enter upon
t constuctloryerWdpropetyor In mprexnpurposof the q"t/.)L 1I
N illy loenterecto avehe imleennifyonsdproperty forcas the Cit purpose. ALTEROR ADD TO MFCH.
Z (We)agree na save,Indemnify an d keep rMee the City of Cupertino Date Receipt#
V agaiiut BabNtin,pdgmens,cortsa dex which mayinanywayamue AIR HANDLING UNIT(TO 10,000(PM) SUBTOTAL:
ago of City i`a dna a this permit. -
_/j,90 AIR HANDLING UNIT(OVER 10,000 CFM) 116y CONSTRUCTION TAX
tutufApplicant/ onl EXHAUST ICT)
ctor Data AUST HOOD(W/DCONSTRUCTION TAX PAID:
HAZ3 R DOUS MATERIALS DISCLOSURE
Wilthe applicant or future building occupant store or handle hazardom HEATING UNIT(70 100,000 BTU) Date Recef t#
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the
Health and Safety C Oom 25532(4)7 HEATING UNIT(OVER IOR"O BTU) TOTAL:
ppliantRNonIYllehe tum building occupant use equipment ordevices VENTILATION FAN(SINGLE RESID)
/ � whichemithaaard..aI$$UANCE�
I
tyy Management District? BOILER-COMP OHEPOR 100,000 BTI)
Ye o
0n
have read theft ous materlas requirements under Chapter 6.95 of BOILER-COMP(OVERImp"BTU), �� 1990
the Ce lifomU Health&Safety Code,Sections 25505,25$33 and 25534. 1
understand that ifthe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. /a .a
repo tylon`ifytheompantotthe ulremenls which must be met �I�t/ IGF er1)rnl rl/tO
P.."_,.. nm ofa 10cetc a Y
If
Uwnr authorlssd agent DateISSUED BY:
TOTAL;
OFFICE COPY