24162 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PIRMITNQ 416 2
Building Addrna: Z
a l lD 67ill -'-ar L «
A A
nr. ante: �2 Z7-o28°r CITY OF CUPERTINO-BUILDING DIVISION as. �!1 fl
. c°ntradors 'ne: Lie.No APPLICATION /PERMIT 7-1 t�
'39C 35um c- CATEGORY CONTROL«
Arc Iter/Engine Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: 6 34
(, cl PERMIT ISSUANCE ❑ 1:1 11LICENSED CONTRACTOR'S DECLARATION
I hereby afflrmthat l am licensed under provisions ofChapter9(mmmenc- APPLIANC0,RFS7DENTIAL JOB UE hlll''IION
Ingwlth Sedion7000)of Divikm3ofthe BuslnessandProfesslonsCode,and my
c�� n ° and��4 390. 5 PANELS
G�}Z Q.tFY
� Contractor ttSOflfy
ARCHITECPS DECLARATION / 201-1000 AMPS
Z Iunderstand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.Ff.
O
� �j Licensed Professional SIGNS ELECTRICAL
< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
7 L., I hercbyam fOrthatl am exempt from the Contractor's License Lawfarthe
pp following reason.(Section 7031.5,Business and Professions Code:Any city or
TEMP.METER OR POLE INST.
county which requires laeN"toroorequiesth aprovpdemsuor ch,arrepair mitI
any swcturetatemenIts haancgaicensed requiresthethe provisions
of permit POWER DEVICES
C floe a signed statement La that he h r 9(earn pursuant it the pro 7000) of the
Pw Contractor's LicenseLaw(Chapter9(mmmendngwith Smptthemfm and
5 O SWIMMING POOL ELECTRIC
sion3of the Businemand ProfmlovCode)orthat he beam therefromand VALUA'�1(�/1��-�
Q S"S the basis for the alleged exemption. Any violation of Section 7RHS by any OUTLETSSWITCHESFIXTVRES C a �D
$� appli..tf.r.permit.bjed,theapplicanttoadvilpe®Itya.n ..than
ro five hundred dollars($500). NEWRESfDFNTALELECTR FT. STORIES TYPE CONSIRUC'1'ION
^ IRUSpD�I• as owner of the property,or my employees with wages m their sok
7acot, it wilido the work,and ahestructure b not intended or offered for
p sale(Sec 7014,Business and Peefeadoro Code:The Contractors License law
�$ does not apply to an owner of property who Wilds or improves thereon,and IN I
c who does such work himself or through his own employees,provided that such ^ -r�R RFS.UNITS
improvements arenot intended oroffered forsale.If,however,thebuliding or \TOTAL:
improvement beold wlthlnoneycarofcompldiogtheowner-buRderwill have
thS.barden of proving that he did rest build or 4nprove forpurpose ofsak.). QTY. PLUMBING PERNE APN
L_I L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
.i.e.to construct the oroµa(Sec.7014,Beat..and Protessimet Code: 'j
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN VENT-NATER(EA)
Wilds or Improves thereon,and who contracts for such p(ajects with a
�gNladm(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sr. B &P C for this reason
•
Owner Date
DRAINS R FLOOROOF,AREA,COND. SANITARY Y N
K
WORMAN COMPENSATION DECLARATION RECEIPT«
Y_ N
01 hereby aRirm that I have o Insur, opyaFD(TURF_S PER TRAP SCHOOL TAX
to of consent to -inre,or
certificate o(Worken'Comperwtlonlruurance ora rcrti(kd copy thereof(Sec. RECEIPT«GAS EA.SYSI'FM-1 INCA OUTLETS PARK FEE Y N_
3800,Lab C.)
Policy«CoGAS EA.SYSTEM-0VER4(EA) BUILDING DIVISION FEES
�Certifie pybhereby furnished.
{y�Certifled copyb(Iled with the city lnspedlon division. GREASE/INDUSIRL WASTEiMFRCEI'TOR PLANGHECI(FEE
CERTIFICATE OF EX MPI'ION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200Ff. Date RCMI t#
(Thlssectkn need not W comrm
pleted tithe peit b for one hundred dollars
(510 n.) WATER HEATER W/VENT/¢ECTR ENERGY FEE Y N
(cewrtifydifythatInthe pcdormance a(the work forwNch this permit bkaed, N—
I shall not employ any person In any manner a as o m abject to the WATER SYSTEM/,FRFAT7NG
Workers'Compen Ron Lawsof California. Date
��G pAlp
O Z Applicant NEWREADENTIALPLMB. SQ.IT. Date Recei t#
Z O NOTICET LICANT:IL aker ma dng this .ertlflesteoracmption,you
M aubjM to the Worken'Compe a tlonpuwblmuofthe LaWr TOTAL:
P
N Code,you resat forthwith comply with such provisions or this permit shall s BUILDING 'E
W > deemed revoked.
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby afkrtnthat there Is a mnstrudion lendingagenry for the perform ELECTRIC FEE
Oacts of the work for which this Forma b Wated(Sec.3097,Civ.C.) TOTAL:
(� I.enders N. PLUMBING FEE
LL F Lenders Addm<a QTv. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Ircdityo
th.tl have rcadthbappBdonandstateahattheabovelnf.munton
a is l agree to comply with all city and county ordinances and slate laws PERMUISSUANCE FEES PAID:
r relating to W llding construction,and hereby auahorla,representatives of this
Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMSCH.
— (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
against liabilities,jrd menta,rortsandexpenses which may In anywayaccrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
aWtsald Cl i onstyuence of the ant fthb permia.
/ AIRHANULINC UNIT(OVER 10,(00CEM) CONSTRUCTIONTAX
Signatureo Bon"/Contractor Da EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PA ID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BM pate
materlalas defined by the Cupertino Municipal Code,Chapter 9.1 2,and the Reeel t#
Health and Safety Code Section 25532(a)2 HEATING UNIT(OVER 100,000 BTU) F-
yes r]No TOTAN}
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESIT)) ISSUANCE DATE
which emit harar oma air rontamivnts as defined by the Bay Area Air cry
.
Quality Management District? BOILER-COMP OHP OR 100,000 BTU) IG A B
4Yes I�JNo W
have ad the hazar�r� manrials requirements under Chapter 6.95 of BOILER-COMP(OVERIM,000BIU)
the Glifornia Health&Safety Code,Salons 25505,25533 and 25534.I
understand that lithe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECO. SQ.FL AUG1 199?
responsibility to notify the occupant of the requlrcments which must be met
prior to Issuance a a Ccrti Oche of Ocenpanry.
Cl y v / r�{�-}IIr�
Owner or aulhoriud agent pate ISSUED BY. �J
TOTAL:
OFFICE COPY