23382 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMITNO,
Buildleas,
�j4//(w A wDsQle/v - 23382
nets ] / 011e:
CITY OF CUPERTINO-BUILDING DIVISION
_
C
.atractor.Name: I Lk. o: APPLICATION / PERMIT d /`
BUILDING-ELECTRICA PLUMBING-MECHAMCAL CATEGORY CONTROL N
rchltect/Fegineer.
QTY ELECTRIC PERMIT. FEE BUILDING PERMIT INFO
Address: PERMITISSUANCEEJ ❑ [ILICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provlslons of Chapter9(commene- APPLIANCES-RESIDENTIAL JOB DESC ION
Ingwllh Section 7000)of Divis(on3 ofthe Buslnessand PrefrsYons Code,and my
Ilcensv tetra fu l ores and effect PANELS n ((��
Lken a LIc.9 �. ✓ • O" 7- W, r
Date�C,mmoctor #I41 N y
pp ARCHITECPS DECLARATION 201-IOW AMPS
9CO (understand my plawahall be used as publlcremrds. OVER1000AMP5 - EDFL EA $/SQ.FT.
t, Licensed Professional SIGNSELECTRICAL1hereTER
6 ul OWNER-BUILDER DECLARATION
1g SPECIALCIXCUIT/MISC
io., owing rasonn(Sectithat on
ProfeoortC License leen forth, ^
0 Z; following reason.(Semon 7031Z,permit
to BuYnessand Pro ct,alter, prove, Code:Any dry or TEMP.MITER OR POLE INST. f Ila
rr F' countywhichraccum rIeuiresa pert[dtroconatrouirestheaprovent fors ch,orrepair
' ray structure statemurtoent
its that
he Is licensed
pursuant t the provision of t e POWER DEVICES
O Ole a signed Yalelrent IM1at he V IkensM pursuant to the provisions of the
w� Contrador'a License Law(Chap[er9(commencing with Seaton 7000)of Divi-
SWIMMING POOL ELECTRIC
slon 3 ofthe Buelnessand ProfembluCode)orthat bels exempttherchumand VALUATION
the basis for the palleged exemption. Any violation of Seaton 7031.5 by any Cm i
appllczudfora ertNno t subjects the applicant to a civil penalty of nmore than OVIIE.ISSV✓[.fCFifSI7X•fUItPS 5v I
five hundred dollars(SM.
I,as owner of the property, NEW RESIDENTIAL ELECTRSQ.FT. STORIES ' 'IYPECON'SIRIX:TIDN'
�n t, perry,ormy employees is not
r their
C compensatlon,wW Bothe work and thestrudure Vnot Intended or offered for
$ O sale(Sec.apply
to alnowand Profmklu Code:The or impdolsWceonhen
docs not apply to an owner of property who builds orlmpnwes thereon,and
v- whodeessuchworkhinuelforthrough hisownemployeas,provided thatmch OCG GROUT' RFS.UNITS
Improvrhrnb are not intended oroffemd forule.IL however,thebullding or TOTAL
Improvement b sold within mayearo(compldlon,the owner-bullderwlll have
i rdenofprovingthathedkl not build or Improve for purpose of ask,). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
FI,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE /L"/1'(�
contractors to construct the projed(Sec 7044,Business and Pre esslota Cade: ��//�•vv sD�
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN kVENT-WATER(EA)
Wilds or Improves therea
on,and who contracts for ouch ptejes with a
gp(paor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE' "FEE SUMMARY
LII am exempt under Sec. B k P C for this reason
DRAINS.FLOOR HOOP,AREA,COND. SANITARY Y N
Owner Date �F�p p WORKMAN COMP E[g5AT10N DECLARATION FDTHIRESPERTRAP SCIiODLIAX Y N_
hereby affirm that I have• l=nne of consent to self-thence,ora RECEIPT N
cediflale of Workel%Compensationlnaurance oraceml(led copythenmf(Sac. GAS EA.SYSTEM-]INCA OUTLETS 3BW,LabC PARK FEE Y— N_
Policy N_ ed copy i ADO SJ:-1 _ GAS EA.SYSTEMAVER 4(EA) DINGRECEDT p
Com a"Ned
v � BUILDING DIVISION FRES '
ff&d dcopy Vhereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Oyef iffea copy is(Bed with the ay Impact[on division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREISETRAP PAID
COMPENSATION INSURANCE SEWER-SANHARYSTORM E.A. OOFT Date Remi t#
RM
M1Isslan need not he completed If the permit V for one hundred dollarsP
($100)orleas.) WATER HEATER w/vENT/ELECTR D ENERGYFEE Y N
certify that in the performance of thework forwhlch this Permit is Issued, a —
I shall not employ any person in any manner so as to evening subject to the
I
Workers'Compemation Laws of California. ATGR SYSTEM/TREATING
la.Date - PAID
Z Applicant NEW RESIDENTIAL PLMB. SQ.IT. Dale Recel t#
.Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
N should become subject to the Wmken'Comprruat ion provisions of the Labor TOTAL:
Code,you at forthwith comply with such provkiola or this pemdt shall he
W > deemed revoked. BUILDING FEE
W
DNSTRUGTION LENDING AGENCY SEISMIC FEE
I hereby affirmcthat there is a construction lending agency forthe perform ELECTRIC FEE
= Z an of work for which this permit is issued(Sec.3097,C1v.C.) TOTAL:
00 lZare Nana PLUMBING FEE
LL F Lenders Add mss QTY. MECHANICAL PERMIT FEE MECHANICALFEE
O W Imdlythat
ree to e read comply
ith all chyndcuntyordina abovedgate laws
legingt lagreeto complywith and tyandcountyosrepreseand gate PERMIT ISSUANCE FEES PAID:
U) relacityt to
tro he above-mentioned
hereby authorize reprcaentatives purposo(thb
H N city to(We)
agree
ave,Indemnify
propertymr Inspect it purposes. ALTER OR ADD TO MECH.
? (We)agree ro save,in to A an d keep harmless the City of Cupertino Date Reeei t#
V against Babllitles,judgmente,coeteand nsen whkh may in anywayaccrue AIR HANDLING UNIT(TO 10,1100 CFM) SUBTOTAL'
agelnst 1 CI to consryuen oft i o this permit.-,
�i AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
u ppga ntn to ExHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
H,VARDOUS MATERIALS DISCLOSURE-
Willtheappllramorfutambuildingoccupantstoreorhandlehazardous HEATING UNIT DO 100,000 BTU) pate RL'cei t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the -
11,althand Safety Code Seaton75537(a)7 HEATING UNIT(OVER I00,000 BTIO TOTAL:
1�Yea �No
illthea ppllant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) JSSj}ApL`PID�tf•U
which eMt havaldous air contaminant,as defined by the Bay Area Ale
Quality Ma ragvment Dktrid7 BOILER-COMP OHP OR 100,000 BTI()
4 Yin 1�No
havc read thehaza ouseratedalsrequlrements under Chapter 6.95 of BOELER-COMP(OVER 100,003 RTU) MAR 18 1992
the Call(ornk I Icalth k SafetyCode,Sectloms 75505,75533 and 75534.I
understand that if the Wilding does not currently have a tenant,that it is mg NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requlremars which mu at be met CITY L!r LUI'thlllVl)
prior to Issuance of a Certificate of Occupancy. V 7L_
Owner or authorized agent Date TOTAL: ISSUED BY a /y _naci
OFF( E COPY — - -
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