23767 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEWONLY
. Building Project Identification - - PERMITNO.
Bni1di-18,92 ea6wa..- tz.4v . 23767 -
re ams: onA A
e 6L
0,e4,je
2�s3—vTr5*f l CITY OF CUPERTINO-BUILDING DIVISION /r-
c q APPLICATION / PERMIT b
( G 7 BUILDING-ELECTRICAL-PLUNISWC-M CAL CATEGORY CO pyo �]
Archlt �ygiver. M. C'I,t� I Llc.No {.�
1
-1lKRUG �11G 1<4$fI'1 �,,`'BUILDING.PERMITINFO,: .",
--1 QTY ' ELETRICPTIR�_: ";FEE
Address: POWTISSUANCE �� _ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby aff'umthat lam licensed under provisions of Chapmr9(commenc- APPLIANCES 51D L JOB DESC O
Ingwilhse ton7000)ofDivision3oftheBus(nemandPmfesalonsCode,and my WDo�v.S
license is in full to.and effect.
LiceDate n Lk
Cla .N ^�Ow
Date Contractor
ARCHITECTS DECLARATION 11 PS
NOxO O I understand my plans shall be used as public records. O 0 AMPS SQ,FT.FLOOR AREA $/SQ.FT.
NOLicensed Professional SI SELEC � O 0
6 OWNER-BUILDER DECLARATION 51'EC1AL
Zf' � 1hembyafflrmthat Iamexempt fromthe Contractor'sLimew Law for the
pp following reason.(Section 7811.5,Business and Professions Code:Any city or
OZt+ TEMP. OR POLE T." 2 1
�� cwntywhich requlreea permit to construct,alter,lmprove,demolish,orrepalr 7`-eV StAl.$
g a anystmacre priorto Its issuance,alsorequiresthe applirantformchpormitto POWER EVICES
L5 M R U file a signed statement that he is licensed Fervent to the provisions of the '
G61 3 u, Contractom
Contractor.License Law(Chapter 9(commencing with Section 7000)of Divi-
H�O sion3ofthe Businessand ProfenionsCode)orthathelsewmptthemfromand SWIMMING ELECTRIC - VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS TCHFSFIXTURFS O 1
p applicant fora permit subjects the applicant to a civil penalty niece more than 1
N s five hundred dollars($500). NEW DENIAL ELECTR SQ,Ff', STORIES, TYPE CONSTRUCTION
�n ❑I,as owner of the property,or my employees with wages as their sole
mmpensation,willdothe work and thestruclure is not intended or offered for i
Osale(Sec.7044,Business and professions Code:The Contractor's License Law
aS does not apply to an owner of property who Wilda or Improves thereon,and
whodoossuchworkhimel(orthroughhisownemployees,providedthatwch R S
Improvements are not intended or offered for sale.If,however,the building or T
Improvement issold within one yearofcompletion,the owner-bullderwill have
the_kurdeno(pmving that he did red build or Improve(rn purpose cleats.). QTY, ''- '.PLUM$INC}•PERMI`F _ FLOOD ZONE
LJ I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE D TE /y�� ��'
contractor to construct the project(See.7044,Business and Professions Code:
The Contractor.License Law does not apply to an owner of property who ALTER-DRAW&VENT-WATER(EM
Wilds or Improves thereon,and who contracts for such projects with a
c7 factor(s)limmed pursuant to the Contractor's License Law, BACK FLOW PROTECT.DEVICE ` FEE SUMMARY
�j I am exempt under Sec B&P C for this reason
QIlTqinF FEES
DRAINS- ROOF,AREA,COND. SANITARY Y N
Owner Date S FTARECEIPT X
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCLdOOL TAX Y N
❑I hereby.rke.that 1 have a of consent to opythereo ora REAET'N
3800,Lificateab
C.Worker'Compensatloni......ra certified mpythereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Policy#.C.)
Polley# - RECEIPT q
Com any GA S EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
ertlfied copy is hereby furnished. GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
Certified copy&filed with the atyinspeebon division.'
CERTIFICATE OF EXEMPEION FROM WORKERS' GREASE7RAP IPAID l
COMPENSATION INSURANCE SEWRR-SANITARY-STORM EA.200FT. Dale Rece' '��
IThissectionneed not be completedSpermitURA Vre
(Drone hundd dollars
($10())or less.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y _
I.Affythatlntheperformanceoftheworkforwhichthispermitisbwed, 1 C
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING 13 t� —+
Workers'compansatlo.Lawsof Califomis. Date PAID'
O Z Applicant - NEW RESIDENTIAL PLMB. SQ.IT. Date ReCei t#
Z O NOTICE TO APPLICANT.If,after making this Certifkam of Exemption,you
(• shouldbeconnesubjccttothe Workers'Compevatioe provisions of the Labor - .. - O AI
0 Code,you must forthwith comply with such provisions orthis permit shall be
W j deemed revoked: • BUIL ING FEE to
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a C IherebyafRrmehat there is a construction lending agency for the perform TOTAL: ELECTRIC 'E 1
Z once ofthe work for which this permit is Issued(Sec.3097,Civ.C.)
C� O Lender.Name - PLUM C
LL H Lender.Addm.n QT'i':"•. N CHANIGIL PERINIT s :t•C:FEB+" M L FE
O W ess-
1 attilylhat I have read thisapplicationand statethattheabove I format- n
G Is coma.I agreeto complywlth all city and countyordinancaand steed laws PERMTTISSUANCE FE ID:
T N relating toWildingcovttuction,and herebyauthomoireprestmativesofthis
(_ Z city to enter upon the above-mentioned property for Impaction purposes. l ALTER OR ADD TOMECH. ��
_ (We)agree to save,indemnify an d keep harmless the City of Cupertino Date ReC 'Pt#
against liabilllea,judgments,costs and expenses which may in anywayaccme AIR HANDLING UNIT CTO 10,000 CFM) SUBTO L•
againe aid gity i ronscquence of the grant Ing of this permit.
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTIONTAX
iy_ r i h
SISI-gni eaters of plirant/ .ontr or Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX P- D:
HA RDd SMATEAIALS DISCLOSURE
Will the defied tot futurebuildingMunicipal
ode, hhand9.hazardous HFATTNG UNIT(TO 100,000 BTU) Date Recei t
Health
las definedbythe Cupertino2(a)? -Code Chapter 9.17,and the
Health and Safety Code Section 25532(a)7 - HEATING UNIT(OVER 100,000 BTU) 'TOTAL•
❑Yes r]No
Will the applicant air Wm buildingcontaminants
as mcupant Bay Area devices VENTILATION FAN(SINGLE ItESIU) ISSUANCE DATE
which emit ha seems air contaminanb as defined by the Bay Area Air - F�$$ pp +
Quality Management Distdct7 - BOILER-COMP(3FIP DR 100,000 BTU) t� N 1
Yes ❑No
have read thebazardous materials requlrerreenls undcrChapter 6.9S of BOILER-COMP(OVFR 100,000RN)
1 the CavemiaHealth&Safety Code,Sections 25505,25533 and 25534. 1AUG = 7. 1992.
understand that lithe building does not currently have a meant,that It is my NEW RESIDENTIAL MECFI.---SQ FT
raponslbllity to notify the occulta rut of the requirements which most be met
prior to issua not of a Certificate of Occupancy. -
' cy.- CITY yr vurcn U`n,U
Owner or authorized agent Date �/
ISSUE BY: •,A Q y`U
OFFICE COPY