23149 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL-POINT PEN ONLY
Building Project Identification - PERMIT NO.
Budding Address;
23149
sone s ossa:• //^^� yy'� one: - - .APPLICA
+CyA Q�LFr CITY OF CUPERTINO-BUILDING DI ION A
c°"ba r`ossa: - ,. S p APPLICATION / PERMIT
Architect/En er, le BUILDING-ELECTRICALPLUMBING- AL CATEGORY CO
Lic.Na
QTY EL[GT ERM g BUILDING PERMIT INFO
Address: PERMITISSUAN / -' ,0i.0 ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirmthat l am licensed under provisions of Chapter9(rommane- APPLIANC r'DENTIA .O.-O JOB DESCRIPTION
Ingwith SeMon7000)o(Divisimn3ofthe si Band aims Code,and my
limnselsln fur' andeffect raj` P
Limn Cla Lk.p e� / ftp '
Date Contractor (J .
ARCHITECPS DECLARATION ' '1000 AMPS
09z0I understand my plan a hall be used as public records. FR1000 SQ.FT.FLOOR AREA $/SQ.FT.
(� Licensed Processional SIGNS ELEC CAL 1a LZ T z Vs(
OWNER-BUILDER DECLARATION SPECIALCIRCUIT/ SC
Zr.., Ihereby a(firmthatlam exempt from the Contractor's License Lawfor e -
p following mason.(Section 7011.5,Business and Profenlona Code:Any Aty or
OZp:. county TEMP.MFTFAO POLE INST. -
anystm which orlmapwancromnm-quitruct,Mier;theaImprove,liantfm°Wh,orrepair
dtW -
$$ anyatmcture statement
that he Is abo pursuant
t the provisions
of t e POWER D S
�]O (Ilea signed statement that he b,9(culicensed pursuant t°the d n 700f)of the _
�w Contractors urine Law(Cbapter9(mmmethat he th Bempttherefo-mand
O fir' the 3 of basis for
the
eed Professions Code)orlation f exempt therefrom and Lw*
GI'OOL ELECTRIC VALUATION
G the bean for the permit
subjects
exemption.'Any violation of Secpenalty
o nor m re any OUTLETS-SWIT'rHES-FIXTURES
live hundt for red
perm(S500)cte the applicant to a civil penity of nM more flan $
five hundred dolowner
of the pr. NEW RESIDENTIAL ELECTR SQFr. STORIES TYPE CONSTRUCTION
❑I,as owner will
the property,or my employees is
with wages as their dole
compensation,]a(B, 0K Business work ansae,nd the Code:The
h nm Intended or offered for
sale(See 7044,toanow andf property Code:The Contractorstheene Law
�a
does not apply torn ownerruthroghis o builds
emplrimproovided thatand -such OCC.GROUP RES.UNITS
�F wprovementssuch am rmintended orwghed owns.If,hoes,p however,
building
or
improvements am notit Indneyeartered(oreion,th howovequlder ill haw I - TOTAL: (j
Improvement uemld wlthinoneyearm(completioMrhe awnervbu0derwill have -
t rden of proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING'.PERMIT FEE FLOOD ZONE APN
L as owner of the property,am exclusively contreeing with licensed PERMIT ISSUANCE
centractom to conumd the pmject(Sec.7014,Business and Profession Code:
The Contractor's License Law does not apply to an owner of property who
builds or Improves thereon, and who contracts for such ptojects with a ALTS-DRAIN&VENT-WATER(EA) - FEE SUMMARY•
cgnlractw(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec' B &P C for this reasonOUTSI DE FEES
Owner
DRAINSLD
FOR •ROOF,AREA,COND. - SANITARY Y N
- Date ; RECEIPT p
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP 0 V SCHOOL TAX Y N
❑I hereby affirm that I have a certificate of consent to..11-meure,or a RECEIPT B
certificate ocWorkers Compensation Insurance or a certified copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,Lab C.) .
. - RECEIPT I
Policy M GAS FA.SYSTEM-OVER 4 MA)
Com any BUILDING DIVISION FEES -
ECedifledcopybfiereby ledwththecid. - GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
Certified copy b filed with the city inspection division. -
CERTIFICATEOFEXEMPTION FROM WORKERS' ORFASF7AIr PAID
COMPENSATION INSURANCE - 44M Y Date - RIpt�
(Thlssection need not becompleted lithe permit ls(°ronehundred dollar. -
(8100)mrlese.) IyAJINPY71 ENERGY FEE Y N
l certify that In the Nrlormanceof the work forwhich this permit is issued,
I shall not employ any person In any manner so n to become subject t°the - WA SYSTEM/TREAT[N
Workers'Compensati°n Laws of California.Date PAID
QDate Z Applicant NEWR cel t# L
Z O NOTICE TO APPLICANT:If,after nuking this Certificate of Exemption,you
F- should become subject to the Workeis''Compenation provision of the Labor TOTAL:
N Code,you must forthwith comply with such provblon or this permit shall be ( NG 'E
W j deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
tl I hereby affirm that there is a construction lending agency for the perfore, O(/ ELECTRIC FEE
D 2 sore of the work which this permit b Issued(Sec.3097,Civ.C.) TOTAL: —_
(� O Lenders Name PLUMBING FEE 19&fic2c
F Lender.Addrom QTY. MECHANICAL PERMIT FEELL MECHANICAL FEE
OW Imrtt.I hatl agrecto coeadthbappliotionarul yandcuntyonfiheahove information
1 .b mingt lagreeto complywith alld hemb ..th.r ereprresnd etatelaws PERMITISSUANCE FEESIrcitymistoenter ponteabow-oryanddpropauthorize represenpurposoffhb N ctt(Wa)aeree tosaeabove-mentioned property lsste Cit of Cuer ALTER OR ADD70 MECH. �"`c`ip0
? (We)agree Imsave, ent,co isand keep eswhi h the City y Cupertino Date ReO t#
-V againstll mid
n=sequencetsand expenses which pmay Inerms any wayaccme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against uld City In consequence of the granting oRMe permit
• AIR HANDLING UNIT(OVER 30,000CFM) CONSTRUCTION TAX .
Signature of Applicant/Contractor Date EXHAUSTHOOD(w/DUCT) CONSTRUCTION TAX PAID:
'HAZARDOUS MATERIALS DISCLOSURE �
Willthe applicant orfumm bulldingoccupant store orMndle hazardous HEATING UNIT(TO 100,000 BTI)) Date Recei t# 6:5 a
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section ZS532(a)? - HEATING UNIT(OVER 100,000 BTU) - TOTAL:
❑Yes I]No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE -
which eMthmard°us air contaminants as defined by the Bay Area Air ..
(
Iity Management District? - BOILER-COMP(3HP OR 100,000 BTUp� Q g) BS Q. I D
LL Yen �❑1 No (�
shave read the hszartlmusrruterizls requlrermnts under Chapter 6.95 of BOILER-COMP(OVER100,000 BTU) �r—p�'�-f'�`
the California Health&Safety Code,Sections 25505,75533 and 25534.] - ^�fdf11Y 6 N 1992
understand that if the building does not currently have a tenant,that it b my NEW RESIDENTIAL MECH. SQ.FT
responsibility to notify the occupant of the requirements which must be met ,
prior to Issuance of a Certificate of Occupa ney. -
Y Of" jlyl4tINU59 '
Owner or authorized agent Data )SSUpp
TOTAL:
OFFICE COPY