23502 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
building project Identification PERMITNO.
Building Address: 23502
Z i 39 8 j ne4 eo r ])r.
Here ante: rmc: A A A
�� /0 CITY OF CUPERTINO-BUILDING DIVISION _
cnnaadnra Naos a=.Nop APPLICATION /PERMIT L
Q AC-I/— C.I-(CA 3 / 7 CATEGORY CONTROL
BUfLDINGELFCTRICALPLUMB4NGMECHAMCAL
Architect/Engineer. Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Aadrea.
PERMIT ISSUANCE FIQIO 1:1 ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby ahatlam Bernard!under psof Chaptrr9(comment, APPLIANCESRESIDENTIAL ppp,���yyy
JOB DESCRIPTION
inSecti0A700fDivf3oftheBusinessandPm(essionsCadie,and
license
Ibinfull
force and ect. o PANES
c.N
Date Contractor. 201IODOAMPS
ARCHITECT'S se LAUP TO 2DO AK5
R Oy/ U��a, OVERIODOAMPS SQ.FT.FLOOR AREA E/SQ.FT.
Roo
Iundentand my plans shall be used set public records. �/
Es d of Licensed Professional SIGNS ELECTRICAL � ' '
�¢ OWNER-BUILDER DECLARATION SIrECIALCIRCUIT/MIST ED N'
t- r Ihercby a(Orm that l am exempt from the Contractor's License Law for the U T E
F O t-8 following reason.(Section 7031.5,Business and Pro(easions Code:Any city or TEMP.MEHR OR POLE INST. P
countywhich requires a permit to construct,alter,bnprove,dennlbh,or repair
G .s any structure prlorto Its Wuance,also requbesthe applicant for such permit to POWER DEVICES
^'0 ilk a signed statement that he is Ilcensed pursuant to the provlrlore of the -11Z.41 �f
3 w Contractor.License Law(Chapter 9(comma ncing with Section 7000)of DIVI- SWIahENG POOL ELECTRIC L/ UATIO
O sion3.fthe Buslnessand Prof.x .Code).rth.thebexem themfmmand
the basis for the alleged exempt... Any violation of Section 7031.5 by any
i�<5OUTLETSSWITCHGSFIXTURES C
gO appncantfora permiteubjeda the.ppllcanitoadvll penalty or not more than J OGS,
„ $ five hundred dollars($500). NEW RESIDENTIAL ELECTR FT. STORIES TYIPE CON57RIKTION'
.- ❑I,as owner of the property,or my employees with wages as their sole �'
comperaation,wWdothe workk,andthestmdure is not Intended or offeredfor
to(Sec.7044,Businese and Por essloru Code:The Contratara License Law
c $ does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP RES.UNITS
F$^ whodoesauchworkhtmxlfwthr ghhisownemployees,ptvvidedthatwch
Improvements arc not Intended proffered for sale.If,however,thebuildleg or TOTAL:
Improvement issold within oneyearofcompltion,the owner-Wilderwill have
Bp*rdenof pmvingthat be did not bund or Improve for purposeofsale.). QTY. PLUMBING PERMIT FEE
L j L as owner of the property,am exclusively contracting with licensed FLOODTDNE APN
contractors to construct the projM(Sec.7046,Business and Pmfessims Code: PERMIT ISSUANCE
The Cmdratars License law does not apply to an owner of property who
ALTER-DRAIN&VENT-WATER(FA)
wilds or Improve thereon,and who contracts far ct
such pwjea with a FEE SUMMARY
offftor exempt
under See.
the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ f am exemp under Sec. B&P C for this rcawn
011TRIPIE FEES
DRAINS FLOOR ROOF,AREA,COAD. SANI'T'ARY Y_ N_
Owner Date RECEIPT N
WORK MAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y_ N_
❑1 hereby affirm that I have a certificate of consent to sen-Inure,or a RECEIPT N
certificate./Workers'Compmddtonrrauranceoracertlftedropythereof(Sec. GAS EA.SYSTEM-1 iNCAOUTLETS PARKFEE Y N
3800,Iab —
PoliryN ioC7v b/—/Z n GAS EA.SYSTEM-OVER 4(EA) DING DIVISION
Com aov .S ncr C.i �l.Lfn/ BUILDING DIVISION PG[5
�etined copy b hercbytumecity CREASE/INDUSIRLWASIEINI'FRCEPTOR PLANCHECK FEE
�cemned ropy b plea with floe city Inspection division.
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200Fr. Date Recei ted
(This section need not be,completed If the permit is forme hundred dollars
($100)orlesa.I WATER HEATER w/VFM/ELECTR ENERGYFEE Y_ N_
I acrtfy 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 WAT R SYSTEM/TREATING
Workcrs'Copensxtion Lawsof California. Date PAID
m
Z ApplicantNEW RESIDiIJ'RAL PLMB. SQFr. Date Recei t#
Z, O NOTICE TO APPLICANTIf,.Aer ma king this Certincateof Exemption,you
should become subject to the Workers'Compereatlon provisions of the Labor TOTAL:
CCw Code.you=at forthwith comply with such provisions orthb permit shall be BUILDING EE
LU j deemed revokes.
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL I hereby work
for at themwhich
bacorawctssud(Sec.ton 3097, iv.C.) TOTAL:
TOTAL: ELECTRIC FEE
7 Z anceufthe work(or which Nis permit is Issued(Sec.3097,Civ.C.I
O der.NaPLUMBING FEE
LL H LLeneome
LL der',Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Tced.I hatl agree to
have read ty with pBcitiond county te thatthe ordinancescdgatemlon
ws
0. broirgt.l ildi.g.o tp i.., ndhembautha ordinances gate laws PERMIT ISSUANCE FEES I
} W
city to
enter
rupont rovtwtron donde property
or tmpmlxnpurpo of this
dt(Wr)aeree to ave,Indemnify and
property(or Wpe Cit purposes. ALTER OR ADD TO MUCH.
_ Z Date Receipt#
M'e)agree to save,Indemnify an d keep harmless the City of ayamina SUBTOTAL:V agaWtliabllllies,j�dgmenb,roseyy and expense�A(whhis nay In anywayatme ARIIANDUNG UNTr(x010,000 CFM)
;I Vs dCity In ronxqu n fof)3 gra t16d fthlc permit.
0�A N ����� � /v ARI-IANDUNc uMT�rovFx 1D,DBocFM) CONSTRUCTION TAX
ri raure of�plipbt/ ontador D' EXHAUST HOOD(W/OUCH CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle havrdom HEATING UNIT(TO l00,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I leallh and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BM TOTAL:
❑Yrs rla��No
WdItheapplivant or No
ordevices VENTILATIONFAN(51NGLERFSID) ISSUANCE DATE
which eat harardous air contaminants as defined by the Bay Area Air p
Quality Management District? BOILER-COMP OHIPOR 100,"BM P pr, � D
4Yes ❑❑No
havereadtheh.2usnaterialsrequirementsunderChapter6.95of BOILER-COM P(OVERI00,0006TEA
the California Health&Silty Code,Stolons 25505,25533 and 25534. I APR 8 1992
understand that if the building does not currently have a tenant,that it is my NEW RESI DFNTIAL METH. SQ.I7.
mspo bllity to notify the otu�ant of the requ' me nn which must be met
prio Issuance ofaCcrtlOc'a of0@v pa
vz< CITY OF
nc thori a not I Date TOTAL: ISSUED BY: IP
OFFICE COPY