21493 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
-
Building Project Identification PERMIT NO.
Building Address:
ioz(b -DUW, A EUD 21 Ov,
wners acre:
TT-- one; AM
WeUS tA26o CITY OF CUPERTINO-BUILDING DIVISION
c°^t¢¢.LCct°°��aName: LIoNo: APPLICATION / PERMIT
�s.7ze SYf�iZC Y!'IGG BUILDINGELECTRICAI.PLUMBINGMECIMNICAL CATEGORY CONTROL
Archl /
Lk.No:
f I•I J QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: A)u,,i- su/'tf I So
PFRhIT755UANCE ❑ O � �(1
LICENSEDCONTRACTOR'S
under provisions
RATION LTJ
I MhSedioreby irmthat fDimsi 3oftheBusi mandsrofmionsCodrommenc- APPLIANCESRFSIDENML JOB DESCRIPTION
in ems,i Section force of DlNfect. lthe Buslreuand Pro(esslonsCode,and my
license i•in full force and ellea. .rp (Ix�^fL PANELS
Lftee
DataH" ContractorUP TO 2DDAW3
ARCHITECTS DECLARATION 201400IAMPS
WzIuna my mehade,7used as public records. OVER1000AMPS SQ.FT.FLOOR AREA $/SQ.FT.
00 hi5 Llensed east SIGNS ELECTRICAL
<<< OWNER-BUILDER DECLARATION
1'n� SPECIAL CIRCNT/MLSC
0FR owing affirm(Section 7031.5,
B(romthe Contractor'sLicenseLaw for the dtyor
lolbwingresann.lection7m1.5,Business and Professions Code:Mycityor
O g TEMP.ME7I0t OR LEI ST. -
�� oauntywhich requUesapermitromrotmct,alter,impmve,demolbh,orrepalr
anyslmcturepr rwilt suance,alaorequlreatheapplinntfwmchpert tto POWER DEVICES
L3 file a signed statement that he is licensed pursuant to the proiak ru of the
Gb1 Contractors License,Law(Chapter 9(commencing with Section 7000)of Divi.
sion3 of the Business and Pd.iom Code)or that he Is exempttherefrom and 'SwM'w POOL EL C VALUATION
'S the basis for the alleged exemption. Any violation of Sectio70315 by any OUTLETS ES
< appBonl fora permit subjectstheapplicant to a dvil penalty of not more than
it hundred dollars(S500). NEW D EL TR SQ.Fr. STORIES TYPE CONSTRUCTION
7 6 N I,as owner of the property,or my employers with wages as their sole
compensation,will do the work and the stmorms Is not intended or offered for
❑
sale(Sec.7094,Business and Professions Code:The Contractors Theme law
S� does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RES.UMTS
whodoessuchwork himself orthreugh hlsownemploycee,provided thatsuch
improvements are not Intended oroffered for sale,If,however,the building or TOTAL:
improvementissoidwithhnormyear°(completion,iheown 2'HderwBlhave
ltiLkurden of proving that he did not Wild or improve for purpose o(sale.). QTq &KLmUING PERMIT FEE FLOOOZONE APN
LJ 4 as owner of the property,am exclusively contracting with licensed ISSUANCE
contractors to construct the pmject(Sec 7014,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who I A -DRAW&VENT [F A)
Wilds or improves,thereon,and who contrafor such p5njaers with e
&or(.)licensed pursuant to the Contractor's License Law. FEE SUMMARY
LJ I am exempt under Sec. B k P C for this reason A FLAW OTF<T.D E
DRAINS A ND. SANITARY - Y N
Owner Dee RECEIPT 9
,�.p,Bp WORKMAN COMPETISATION DECLARATION 17X.RJ S SCHOOL TAX Y_ N_
IAy hereby a(llrm tha I have a certi0cale of consent to self-innate,ora RECEIPT'M
certiicele of Workers'Comperoalionlnsunnceoraertl(led copy thereof(Sec. GAS EA. 1 40 LTS PARK PER Y N
3800,Lb C'
Po11ryN oS7 —/�SIZ
Com any GAS EA.SY V4(EA) RECEIPT
BUILDING
DIVISION FEES
LJ11mued copy is hereby earelshed. CREASE/INDUSIRL ASIS INTERCEPTOR PLANCHECKFEE
E]CertRled copy b filed with the city inspection division.
CERTIFICATEOF EXEMPTION FROM WORKERS' I GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date Recd tll
TThhssectien need not be completed lithe permit b(or one hundred dollars ENERGY FEE Y
($1l
I cem - WATER HEATER W/VENT/ELECTR N—
ertlfyth performance In the per(ounce ofthework forwhkh this permit is issued,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compcnsatiem Laws of Callfornla.Data PAID
- O Applicant Date Reeei tp
2 NEW RESIDENTIAL PLMB. SQ.FT.
Z O NOTICETO come su APPLICANT:If,after makinrs'Co perhis ation ateo(ExempteLyou -
should becorresubjecttothe Workers'Campensatlon provisions of the Labor TOTAL:
I N Code,you=at forthwith comply with such provisions or this permit shall be BU
ILDINGTEE
W 7 deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
C G Ihfthe orkfo which
rei aconstvctlon lending 097,agencyCiv.C.)
pedarm- TOTAL: ELECTRIC FEE
7 Z ance°fthework(or whkhthls permitbbeucd(Sec.3097,Civ.C.)u2 Lender's Name - PLUMBING FEE
LL 0 Lender's Address a QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icea.Iagree aveto
roadtcomply
wiapplcdlonaMtlaty ardiheabove Information
(L lsatingt lagreeto complywilh alidtyand auhommrnanme and gate lawe PERMIT ISSUANCE �d�' FEES PAID:
} Matingtomabove,ogand dprop authorize rcprexntatlaes purposo(thb wnas
H y city to enteruponto seeabovcotify an
propertyforInspection purposes. ALi1R ORADD70 MECH. 6l.to
? (We)agree to save,indemnify and keep harmless the City o(Cupertlno Date ReCei tic
O against liabilltl judg ,c sandexpenseswhkhemylnanywayacwc AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL:
against uldC yl co ere ence oltM granting°f this pertnll.
jhg 1 AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
I- yt_q v
gnatueo( ppll nt/C ttrador J Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
I DOUS MATERIALS DISCLOSURE
'Will ppOcentorfuture building pact store or handle harardous HEATING UNIT(TO 100,006 BTU) Date Recei to
material as defined by the Cupertino Munhdpal Code,Chapter 9.12,and the
Health and Safety Cade Section 25532(x)2 HEATING UNIT(OVER 100,000 BTU) TOTAL:
I 1 Yea j�j No
Ill theapplicant or for..buildingoavpam.so equip.etor device VENTILATION FAN(SINGLE REBID) ISSUANCE DATE-
which emit hazardous alr conta Mnants as de0nod by the Bay Area Air qsf�
Quality Management District? BOILER-COMP OHPOR 100,DOD BTU) r
Yes No
have read the baza 'usmaterials requirements under Chapter 6.95 of BOILER-OOMP(OVER 100,000 BTIA
the California Health&Safety Code,Sodium 25505,25533 and 75534. 1 NOV 2 9199) -
understand that if the building does not currently have a tenant.that It Is my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to ratify the occupant of the requirements which moat be met
prior to Lsauarm of a Cchif tate of Occupancy.
n1 ,�rte'
Owner or authorized agent Date A ISSUEDBY_
:
TOTAL: Ca
OFFICE COPY