21711 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification L_Q- - 2 A.Ox PMWTNO.
as ,ing Addnsa: J Ll
16 o y 9- �D c ��ti �� G 21711
one. A A
CITY OF CUPERTINO-BUILDING DIVISION 1
ractorname, APPLICATION / PERMIT
BUILDINGELECTRICALPLUMBING-MECI IAMCAL CATEGORY CONTROLN
en/ ghee
r (I QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address UM
P13MTIS5UANCE
III- LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am lleanaeel under provisions of Chapler9(common AP7LANCESRESIDEM7AL JOB DfSCRiPHON
Ingwith Sectlorof fat 3ofthe BusmcaandP�wpfralonsCude,and my
license le Ins I and dfect. C PANELS
ClaL1c.
Wfi ss
Date Contractor ' UP TO 2DO AMPS
ARCHITECTS DECLARATION 201-1ODO AMPS
07O l understand my plans shall be used as public records. OVER .Fr.FLOOR AR $/SQ.FT.
Fj Licensed Professional - mcNSELsc c 63 r-s
Q OWNER-BUILDER DECLARATION Sm:CIALC I /VJ•,a./J(
i., ? 1hembyafflrm that 1.m.xempt from the Contractor:License Law for the
7 p„ following mason.(Section 7¢71.5,Business and Professions Code:Any city or l l
QLF. IUIP.MECFR ORPOI. ST. 7
�4 county which requires a permit to construct,alter,Improve,demolish,or repair
1 anyrtructun prbrto ltsbwarce,aiso nqubeathnappllcant!grouch permitto rT
POWFR EVICES
F� file a signed statement that he is licensed pursuant to the proeblom of the
O�aG Contractor'..License Law(Chapter9(mmneneingwith Section 700(1)of Diel- SWIMMING POOL ELECTRIC
SR 5sion3 ofthe Business and Prefessbm Code)orthat he b exem therefromand VALUATION
he basis for the alleged exemption. Any Adele.of Section 7MI.5 by any OUTLETS-SWITCHES FIxrURES' /S/�
Qat applicant fora permit subjects the applicant to a civil penalty of not more than (J(/
nG �
five 1,asrewn,rofthepr. NEWRISIDFNIIALELPG'IR SQ.FT, STORIES TYPECONSIRUCTION
❑I,as owner will
the property,or my employee with wage an their sole
C�< compensation,wllldoHa wwkand thertrutuld land Intended or offend for ,
O
sale(Sce.7011,Business and Peafesloes Code:The Contractors License Law ,
does net apply to an owner of property who builds or i mproves Ihemor,and
FS^ whodoesuchworkhimseB orthmugh hbownempleyees,provided that such
OCCGROUP RkS.1/NI75
Impmvemeds am not Intended oroffend forsale.If,however,thebuildlng or TOTAL:
Improvement bsold wllhlnoneycarofe mplelon,theowner-builderwlll have
t rden of proving that he did not bund or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLDOD ZONE APN
"L as owner of the property,am exclusively contracting with licensed
contractors to construct the pmjd(Sec.70K B..I...rul Professions Code: PERMIT ISSUANCE
The Contractor's License Law dm net apply to an owner of property,who ALTER-DRAIN 4 VENT-WATER(FA)
bund. or Improve thereon, and who contracts for inch projects with a
C�0.t ator(s)Bernard pursuant to the Contracts License Law. RACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B k P C for this reason
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N
• Owner Date ld ora RECEETN
WOR"m=t COMPENSATION DECLARATION FIXTIJRFS PER TRAP 5QdOOLTAX Y_ N_
01 teof affirm that I have o certificate of concent to"If-Insure, RECEIPT N
MM,
o(Workeri Compers,ugnlmurancemaartllled copy thenw!(Sec. GAS B.A.SYSTEM-1 INCA OUTLETS PARK FES Y N
P W,Lab CJ Co
N GAS EA.SYSTEM-OVER l(FA) RECEIPT N
Cenv s-�xla0 1.p'nG• l..v BUILDING DI VISION 41iG5
�Ccrtlfled copy is hereby furnished.
cGREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified ropy b filed withhthethe city inspection division.city
CERTIFICATE OF FXMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SAn7TARY-STORM FA.210FT. Date Reoei tic
(This section need net be completed if the permit b for one hundred dollars
RI00)orle that
WATER HEATER W/VENT./FLPGTR ENERGYFEE Y_ N
I cent that o1.the performance of smarter so as to
this permit la issued,
I shall not employ any person In any rtanner at as to become objet to the WATER SYSTEM/TREATING
Workers'compensation Leve of GII(arnh. Dace PAID.
.
O Z Applicant on,you NEWRESIDEVRALPLMB. SQ.FT. Date Recei tN
Z O nOTTCEiOe,subj APPLICANT:If,after nakingthb Certificate pr vetons oft eLaho
� should become aubpt to the Worken'Compematlon provblov of the Labor , TOTAL:
N Code,you must forthwith comply withmch provisions orthb percm.hall be BUILDING FE'
W j deeed voked.
d mreO CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that them ,a Conswction lending agency for the perform ELECTRIC FEE
Z ante of the workfor which this per Ibis ed(Sec.3097,CIv.C.) TOTAL:
00 tender:N.. V PLUMBING FEE
LL F tender.Addma QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O O JrenuythaahavemadthbappIiRan aMYatematthc.bmaJnfornutlon
LU isconmt.building complytion,.clcityandhamb csuntyord repress and state laws PERMITISSUANCE P:41 InD: —
} N rey0ngtobuilding the abmNon,coned proprtyorl for in representativespurposes.
, ly
~ Z cityWe)agee to enter to the above-mentioned lmpeharmlls the Cit purposes. ALTER ORADDID MECH. Date Receitic
_ (We)agree to save,Indemnity an d keep es Which
the City y Cupertino F
against said
City ....equec. Nin expenses whkhmay ln any way accrue AIR FIANDUNG UNIT(7010,000 CFM) SUBTOTAL:
against old City In consryuence o(the grant dthb permit.
/ 1 AIR HANDLING UNIT(OVER 10,o00CI•T1) CONSTRUCTION TAX
2—
Signature of Applkan murator — Date IXHAUSTHOOD(W/DUCT) CONS ON TAX PAID:
HAZARDOUS MATERIALS DI CLOSURE �_JIat
Will theappllcant or future building occupant store or handle havardous HEATING UNIT(TO IMW0 BTU) RCCeI tq
material a,defined by the Cupertino Municipal Code,Chapter 9.12,and the
F Iealth and Safety Code Section 25532(x)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
F-1Yesri No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RF_SID) ISSUANCE DATE
which emit hav mous air contamim els as defined by the Bay Area Air
Quality Management DisMu 7 BOILFA-COMP OFB'OR 100,000 BTU) '""o-O
Ye FF��No P.G'yN
haeercad the th&a materials Sidon nmenbunder ndChapter 6.95 of BOILER-COMP(OVER 1W,OW BN)
the Gltandt at if
f Health&Safetycods not
mlyh 25533 vete tenant,
1 FEB 1 g 1991
understand that l(the building don not anently haveatenanL that ltbmy NEWRESIDFNBAL MECH. SQ.FI
rmpomibllity m ndlty the occupant of the requimmenU which must be carat '
priortoiauance fa Certi'a ofOmr nry.
C � z-5y� _�'lY M Atnr
d
Ownerorxu laagent Dam
TOTAL: ISSUED BY: '�1 _ VtAIWsI
OFFICE COPY