21829 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: f'�1 ("1 n n
Ifo 11�cC1 F�� fJ eQ Gv R 1 o C G 829
sera ame: one: A A A
—Jrokjofir--'2-(p�OZ CITY OF CUPERTINO-BUILDING DIVISION
e°ntradm•aNane: Lic.No: APPLICATION / PERMIT ` l
,� BUILDINGELECTRICAL-PLUMBING-MUCETAMCAL CATEGORY CO
Archited/Engineer, Lic.No:
QTY ELECTRICPERMIT �''a FEE BUILDING PERMIT INFO L
Address: PFRMITISSUANCE ' CID ❑ Imo' ❑ ❑
LICENSED CONTRACTOR'S DECLARATION 1�
Iherebyaf/lent that l am licensed under p.Bkmsof Chapter9(commsnc APPLIANCESRESIDENIIA, JOB DESCRtPHON
Ingwith Ssslon7000)of Divisim3afthe Businessand Pmfese msCode,and my
license is in full force and efre it PANELS F
LicenseClass Lic.# O. r
Date Contactor Y
ARCHITECPS DECLARATION 201-1000AMPS
NO Z I understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
COC
X U Licensed Professional SIGNS ELECTRICAL
6 to
OWNER-BUILDER DECLARATION SPEGIALCRCUIT/M]SC
�i--„
Lp, � Iherebya(flrentleglamexempt lromtheC ranicumeLicense Lawforthe II
O Z E.u9 (S
following reason. ection 7031.5,Business and Professions Code:Any dty or \
F TEMP.METER OR POLE INST.
mu my which requlm a permit to construct,alter,Improve,demolish,or repair v
any structure price to its issuance,also requires the applicant for such permit to J
3 V file a signed statement that he Is licensed pursuant to the provulons of the TOWER DEI�CFS ./ j1 U T E 1
$3u,�
O Contractors Lice"..Law(Chapter
9(commencing
with Section 7000) fDivl- SWIMMING POOL ELECTRIC -n�VALUATION
donaftheBudaandMsslamCoe)orthatheempthem(mmand
Y\
~FS STI the bash for the alleged exemption. Any violation of Stolon 70712 by any OIlILEISSWITCI-BSFlXIURFS i
O
applicant for a permit subjectsthe applicant to a chAl penalty of not..than
$ ftyp�undmd dollars(S500) NEWRFSIDEMIALELECTR SQ.FL. STORIES TYPECONSTRUCTION
k7Q �" as owner of the property,or my employees with wages as their sole
compensation,will dothe work,and thestruaure Is not intended or offered for
S O
.Is(Sec.7044.BusNess and Pmtesslon Code The Contractors License Law
�S$ does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RIS.UNITS
whodoessuchwork himself orthrough hisown employees,provided thatsuch
Improvements are not intended oroffed forsale.If,however,thebullding or TOTAL '' LL W�5
Improvement Issold withinoneyearofcompldiogtheownervW Bderwill have
thckarden of proving that he did not band or improve for purpose o/sals.). QTY. PLUMBING PERMIT FEE FlAODZONE APN
"L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(See.7044.Business and Professions Code:
The Contractors License law don not apply to an owner a property who ALTER-DRAIN&VEN7-WATER
Wilds or Improve thereon,and who contracts for such pmajecos with a
c adorn)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
�j I am exempt under Sec. B &P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N
—]I hereby affirm that I have a certificate of consent to sell-Insure,ore RECEIPT If
certificate ofWarkers Compensation Insurance cora certified copy thereef(Sea. GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
3800,lab C.)
RECEB f N
Poilq# CAS EA.SYSTEM-OVER 4(FA)
CoBUILDING DIVISION PEES
Mam an
rilRed copy Is hereby furnished. GREASE/WDUSIRLWASfEINTERCEPTOR PLANCHECK FEE
❑Certified copy Is filed with the city inspection dlvlslon.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASETRAP PAID
COMPENSATION INSURANCESEWER-SANffARY-STORM EA.2(pF1'. Date Remi tri
M
(Thlssioil^need nbecom
mpleted Rthe pedt Isforom hundd dollars
(sIW)arl..) WATER HEATER W/VENT/ELILTR ENERGY FEE Y_ N_
I certify that in the performance of the work forwhich this permit is Issued,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers Corepensationiawsof Ca Ukeenla.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. �F. Date Reeei IN
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subpd to the Wcorkeri Compensation provisions of the Labor TOTAL:
ir L
Code,you must forthwith comply with such provisions orthis permit shall be BUILDING
W > deemed revoked. •.
CONSTRUCTION LENDING AGENCY SEISMIC FEE �
a
I hereby affirmthat there isacommuction lending agency for the perform TOTAL: ELEC'T'RIC FEE `7v
D Z anreof the work for which this permit Is issued(Sec.3097,Civ.C.) PLUMBING FEE
02 Lenders Name
LL 1— LeMcee Address QTY.I MECHANICAL PERMIT FEE MECHANICAL FEL•
OW I cert By that l have read this application and state that the above Information
4 Lsmrrcct.Iagree to comp)ywith all cityand county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. IL to building convection,and hereby awhorlu representatives of this
F Z city to enter upon the above-rrentloned property for inspection pu rposes. ALTER OR ADD TO MUCH.
(We)agree to cave,indemnify an d keep hareness the City of Cupertino Date Receipt#
V against liabilities,Hdgncrds,creased expenses which may in any wayaccrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agaimt Ci inconnsequeofthe, ant gof1hlepemut. AIRHANDLINGUNIT(OVMIQWOCFM) CONSTRUCTION TAX
Z-12_91CONSTRUCTION TAX PAID:
:Signitfeof Applicant d
ontraor Date D(HAusr HOOD(W/DICT)
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant store or handle haaardous HEATING UNIT(TO 100,000 BM Date RCcei I#
material as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Ly
Iiealthand Safety Cede Sedion75532(a)7 HEATING UNIT(OVER 100,(X0 BTU) TOTAL: \X
T� Yes MN.
Will the applicant orfumm building occupant use equipment or d evicen VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which sent herarAom atr contaminants ae defined by the Bay Area Air
Quality Management District? BOILER-COMP OEN OR 10,000 BTU)
yes, No
have read the haasmdcxus materials requlremenb under Chapter 6.95 of BOILER-COMP(OVIR 100,000 BTU) }�
the California Health&Safety Code,Sections 25505,25533 and 25534.I
understand that lithe building does not currently have a tenant,that it ft;my NEW RESIDENTIAL MECH. �.IT 1
resporesponsibility to islityto notify theoccupant of the requirements which must be met y �j
sissuance ofathe occsof aOccupancy.
Owner or authortred agent Date TOTAL ISSUT:D BY:' CJ I �, tl)a�-►
OFFICE COPY