24169 (4) 1
APPLICANT TO FILL IN INFORMATION WITHIN REDLINE S_ USE BALL POINT PEN ONLY
�-
Building Project tdeml(lotlan Pf1LNITNQ 4169
Building Adtlms: Z
a856 Kim Street, Cupertino 95014
Mr. and Mrs. Murray 253-0341 CITYOFCUPERTINO-BUILDINGDIVISION,
(Jwneve one: 44 �J
c°° MNa j� j�q� APPLICATION I PERMIT
t�omme se Constr. 33"572 BUILDINGE.ECTRICALPLL3MBING- CATEGORY CONTROL#
Archeoe I/L neer. MECIIAMCAL
`On�ract Or � Lie.
Adderca. ac r. FLU 5
QTY " , ELECTRICPERMIT FEE BUILDING PERMIT INFO
e n PERMITISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION
Ihercbyafflrm that l am licensed under provisions ofChapter9(mmm _ APPLIANCESRFSIDENTIALBDESCRII'T[ON
Ingwilh Scdi°n70M)of Dlvlelon3°(the BueineaandP feadonedy
-
IlaI lnfull, red ic.If- O PANELS - pw"T1eti0./'
13 CI ss Llc M U
Dal Cantnctor
ARCHITECTS DECLAR 201-1IXI0 AMPS
aO Zp Iundentand my pisco ehaB be usedupu crcmrde. - OVER 1000 AMPS SQ 1/SQ,Ff.
Licensed Profoalmul - SIGNSELECTRICAL 1
Q 6 OWNER-BUILDER DECLARATION
SPECIAL CIRCUIT/MISC
IhcrebyafBrmthatlam exempt Cont Tailor's License hw for the _ -
o following reamn.(Section 7031.5,Business and Pref talons Code:An city or
Ozt- y ty TEMP.METER OR POLE INET,
county which requlrcsa permit bmrutruR,alter,lmpmve,demolish,ormpalr
any atructure prior to lb issuance,also requires the.pplicant for such permit to POWER DEVICES
CL file a signed statement that he Is licensed pursuant to the provisions of the
. 3Or Contractor's Lk eme Law(Chapter 9(commencing with Section 7000)of Divi. SWIMXIINC POOL ELECTRIC '
.17 slon3oftho Buelneseend Pro(eulov Code)orthdhebexemptthemfromand VALUATION
0 7 the bash for the alleged exemption. Any violation of Stenon 70315 by any O()•D,ETSSWI7'CFIFSFIX'TIIRES nn
'
applicant fare permit subjctsthe applicant to a civil penalty of not more than
five hundred delta.($500).❑1,as owner of the property,or my employees with wages as(heir wk NEW RESIDENTIAL ELECTR' SQ.ET. STORIES If TYPE CONSTRUCTION
mmpensat(on,wllldothe work andthe stmdure h not lntendecior offered for
O
-1.&c.7014 Busbiesand Professions Code:The Contractors License law
•t ri$ does.m.pply toan owner of propedywho bulldsor Improves thereon,and OCG CROUP RES,UNITS
whodoessuchwork hlmmlf orthrmgh hlsownemployees,provided lhatsuch OrT
Improvements are not Intended orolfered for ale.If,however,thebullding or
Improvement hsold withlnoneyearo(completion,theowner-buBderwill have '
tta;burdenolpmving that he did not build or improve for purpose of ale.). Qjy, PLUMBING PERMIT '•EFLOODZANE APN
n L as owner of the property,am exclusively contracting with limned PERMRISSUANCE
mntradom to comtmd the pmjed(Sec 7046,Business and Professions Code:
The
ra
Contctors License Law does not apply to an owner of property who ALTER-DRAIN&VENT WATER(EA)
Wilds or Improves thereoq and who contracts for each p(ojects with a - _
c'}Rt(adoral llanxd pursuant to the Contractors Lkenn Law, BACK FLAW PROTECT.DEVICE FEE SUMMARY
bf am eNmj under Sec. B&P C for this reason
�'1 DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N '
OUTSIDEFFES
Owner Date RECEIPT
X -
WOR KMANCOMPENSATION DECLsentto N ED(TURES.PER TRAP SCIIOOLTAX Y N
- ❑T hereby,afilm that I have a art... of consent t°op then re,ora RECEIPT N
3800,certifiabof Worken'Compewtlon Wuanaan certified copythereo(�ec. CA&EA.SYSTEM-I INCA OUTLETS PARK FEE Y N
3800,lab C.)
Policy GAS A.SVSTF.MAVER 4(EA) RECEIR#
Com any BUILDING DIVISION FEES
�Cedified ropy h hereby furnished. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK TEE t •'fib
❑Certified ropy Is Red with the dry Wpectlon division.
CERTIFICATE OF EXEYIPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Thisnttlonneednolbecompidedifthepermit oronchundreddollan SEWER-SANITARY-STORM EA.20°FT. Da RecdpLl
(SI I10)orless.) WATER HEATER W/VENT'/ELECTR ENERGY N 'r
(certifythat In th erfL.ruxafthe wo orwhkhlhla permit is issued, — -
ZIshall not ereplo person In any ma `eo a bespme ct to the WATER SYSTEM/TREATING _
11kcre'Com .rxf Calif ate_? 2 PA .�
OApplicant
Z o NOTICETO ICANT:ILafie ertl(late°f ,con to you NEW RESIDENTIAL PLMB. SQFT. aft I
Hshouldbecomneubjeatot n'Compematlonprovlalomolthe Labor TOTAL:
IXN Code,you must forthwith comply with such provhiom orthh permit shall be B •E
W � deemed revoked.
G CONSTRUCTION LENDING AGENCY SEISMIC •E
1 I hereby affirm that then is a construction lending agency for the perform ELECTRI FEE
Z area of the work farnq hkh t
U O hh permit b blued(Sec.3037,Clv.C.) TOTAL:
ands,.N.roc ne PLUMBIN ,FEE
ly — eraser.nadrea. QTY. MECHANICAL PERMIT FEE MECHANI LFEE
OW lartify that l have re ad t his applicationaM state that theabove Information
1 iscoma.I agreeto comply with Rd III mu ordinanasand sUtelawa PERMIT ISSUANCE ��. PEES PAID:
} N relating to building ronstmcdon,and hereby otlze representatives olthis
1— Z city to enter per the above-mentRmrdp sty(or mpecUon purposes. ALTER OR ADD TO MUCH. s/'
M. agree ve,indemNty an dJ fp harMees the City of Cupertino - Date RecelPtN
V against thio a dgmento costae d' peneeswhich may in any wayamue AIR 1iANDLING UMT(T010,000 CFM) SUBTOTAL:
age lnate conaryuena P granting of this Permit. --
1,� - �-� AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCT NTAX
dffj-ig Teo pIt -e .or Date EXHAUSTHOOD(W/DUCT) CONSTRUCTI NTAX PAID:
AZ RDOUSMATERIALS DISCLOSURE i
Will the applicant orfature building oavpant store or handle hazardous HEATING UNIT OD 100,000 BTU) Date Rec
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the - _�
I Iealth and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU( TO
❑ Yes NNo'
Will the applicant.1 future building ottvpart use equipment or device VENTILATION PAN(SINGLE RESID) ISSUA DATE
which emit hazardous air contaminants as defined by the Bay Area Air pp y
Quality Management District? BOILER-CDMPOFIPOR 100,000 BTU) M /
Yea MIN.
have read the haurdous materiabrc Ant,underChapter 6.95 of BOILER-COMP(OVER 100,000 BTU) Sip
the C Hurela Health&safety Code,SeS1 r(s 75505,25533 and 25534. I SEP .
understand that ifthe building does rrcntly have atenanL that lthmy _ NEW RL'SIDPNfIAL MECH. SQ.FT y-
PMPonsjfiRJtyt.rcxJfythxoc=, t therequlrcmentewhkhmustbemet cilY ua ceof.Certifkccupancy. 9.
ra not en Date
TOTAISSUED BY: _
OFFICE'COPY'