23608 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PERhETNO.
Building Address:
*Y'/ X ,mitis fit, C� er;;r ..� tee, 23608
v 1 .ne: - A
y
�1//Sd�✓ ZJ �.9 CITY OFCUPERTINO-BUILDINCDIVISION
Cgntrador's Name: Lie.No: APPLICATION / PERMIT
S� v BUILDINC-ELECTRICAL PLUMBING-MECHANICAL CATEGORY CONTROL p
Architect/Engleas Lie.No:
�•s QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Adders. U PERMITISSUANCE /(� ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION I[�I
I hereby affirm that l am licensed under provisions of Cha pter 9(commmc APPLIANCES-RESIDENTIAL JOB DESCRPLON
irgwlth Sec4fon7000)of Division3 olthe Busbessand Professions Code,and my
Breese is in full force and effect PANELS
License Cbss Lk.c
Date Contrador 12 TO 200 AMPS
ARCHITECTS DECLARATION 201-1000A.MP8
Q
Z' I understand my plans shall be used as public record& OVERIWOAMPS SQ.Fr.FLOOR AREA S/SQ.Fr.
COC
d U LlceneM Profesaignsl SIGNS ELECTRICAL
w OWNER-BUILDER DECLARATION
In a SPECIAL CEtCUIT/MISC
7t' Ihercbya(Brm that lAnn exempt from the Cgmmdoh License Law for the ov
following reason.(Section 7031.5,Business and Pmfwai,ma Code:Any city or
Fcoumyw,ub requbesapermitMmmMdalter,impmvgdeo iLih,orrepalr TEMP.METER OR POLE INST.
.-r anystructure prlorto Its Ismance,aleorequires theappllant for such permiHo
file a signed statement that he b licensed pursuant to the provisions of the POWER DEVICES
Cmmatim'.License LAW(Cl pler9(conunencingwith Section 7000).(Divi- SWIMMING POOL ELECTRIC
F�Oe ston3ofthe Buslnessand Prof.ss .Code)orth.t hebexempttherefromand VALUATION
•.1 the Web for the alleged exemption. Anyviolationtolatlon of Sedkn not mbyany /_ PAP V-L
GS
applicant fora permit anbjecbtheapplicanttoa civil penalty of not rtnrethan 0[TILETSSWITCIiESflXT[B2F5 r/a'I/—�_
f rclred dollars(S500). NEW RESIDENTIAL ELECTR FI.
�n an owner of the property,or my employees with wages as their sole S ' STOW EB TYPE CONSTRUCTION
C7R co pematloMwilldothe work and thestrudure is not intended or offered for
JF� sale(Sec.7014,Business and Profmions Code:The Contractors License Law
dcos not apply to an owner of property who builds or lmprwea thereat,and GGROl1P RES,UNITS
WW whod«reauchworkhlmseEorthrough hbownempleyees,provided thatauch
s Improvements are not Intended oroffered for sale.If,howevepthebulldingor TOTAL:
improvement lssold withinoneyearo(compldion,theowner-builderwlll have
t)LJIurden of proving that he did not build or Improve for purpose ofule.). QTL PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively=trading with Ilanyd pggMI.1.ISSUANCE
to roretrud the project(Sec.7044,Business and Professions Code:
The Contractor's License law does not apply to an owner of properly who
buALTER-DRAIN&VENT-WATER(EA)
Wilds or improves thereon,and who contracts for such p(ojeds with a
cgp(tactor(,tlanaed purs,I to the Contractor's Lken:Law, - FEE SUMMARY
t amyym)rt�ynd B A P C for this reason BACK FLOW PROTECT,DEVICE
Owner �//�i �/�/ i DRAINS fl.00R ROOF,AREA,COND. SANITARY Y Nr
.Data BBC=If
WORKMANCOMPENSATION DECLARATION
hereby affirm that I have a certificate of consent to self-InapD(TfI[tESPER TRAP SCHOOL 7'A% Y N
ure,'or a RECEIPTNM
cenifiateo(Worken CompematlonlnsuranmoracertifiMmpythemof(Sec. GAS.EA SYSTEM-1 WC401J7LET5
3800,Lab C.) PARKFEE Y_ N_
Policy Y RECEBrr 8
Com an GAS EA.SYSTEM-OVER4 MAI
Y B U I L DING DI VI SION FE ES
CenlRed copy b fieri With the cityed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCI'IECIC FEE
CertlEed copy b flhd with the city inspection division.
CERTIFICATE OF E%EMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATIONINpermit E sEWFRSANRARY-STORM EA.20017. Date ReceI
Qhb section need not be eomplded lithe permit is(Drone hundred dollars pt#
($l00)grless3 ELIL '
Iurtlfy that In the performana.fibs work for Which this permit is batted, WATER HrATERW/VENT/ TR ENERGY FEE YN—
I shall not employ any person In a y manner An u yybylpm� Jo 1 W WATER SYSTEM/TREATING
Workcn'Co9p�satio wef Ifomb.Date .'//.GY Li PAID
Q Applicant r/l rC't C' �f.,,aw/+x,
Z a NEW RFSIDPNI7AL PLMB. Fr. Date Remi t#
Z O NOTICETO e,subl APPLICANT. orkersk ompethisCctionP W,., em -L,a o
ehwldbm.matfort with co Workers C.mpeoeatlomprovbknsrmit s Labor TOTAL:
H W deemed r mueHwlhwlth amply with such provisions Drib permit shallbe -BUILDING ••E
� j deemed revoked. 25
W F3 CONSTRUCTION LENDING AGENCY SEISMIC FEE O
I hereby affirm that there Is a construction lending agency for the perform ELECTRIC FEE
Z ance of the work for which this permit In Issued(Sec.3097,Civ.C.) TOTAL:
V'O ]enders Name PLUMBING FEE
LL Lenders Address QTY. MECFIANICACPERMIT FEE MECHANICAL FEE
O W (unify thatf have read thisappliatlon and Antethattheabove information
C incorrect.building comply wo ,alndtyand munorize reprcesand atatelawe PERMIT ISSUANCE rEES,PAIp_
U) relatingtobuilding construction, hereby authorize representativea olthls ��`7� kW
Z city to onter upon the above-mentlon.d property for inspection purposes. ALTERORADDTOMECH. 6
— (WB)agree to save,Ind smelly an d keep harmless the City of Cu Fortino Date Receipt#
against liabilities,Pelgnrnts,mob and expenses which may In any way accrue AIR HANDLING UNIT(T010,000 CFM) SUBTOTAL:
Against said City in consequence,of the granting of this permit.
AIR HANDLING UNIT(OVER to,"CFM) CONSTRUCTION TAX
Signature of Applicant/Contrador Date EXHAUs'r Howov/DucT) - CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appBant or future building eavpamt store or handle hamrdous HEATING UNIT(TO 103,000 BTU) Date RCCCI t#
material as defined by the Cupertino Municipal Code,Chapter 9.IZ and the
HmIth and Safety Cale Section 25532(x)7 HEATING UNIT(OVER 10,000 BTIO TOTAL:
❑ Yea No
Will the applicant orfuture building occupant use equipment or devices VEND LATION FAN(SINGLE REBID) 1$$I pprcl(•FynUYrc
which emit ham edous all cents mleanbas defined by the Bay Area Air Y'-➢i1W '•
Quality Mansgereent District? BOILER-COMP OHP OR 100,000 BTU)
qY:e N. 3 0 1992
fiavc read the haza Dun malerfals rcquiremgnb under Chapter 6.95 of BORER-COMP 100,000 BTU) p[�L�
thv Gs llforela Health&Safety Code,Sed Ions 25505,75533 and 25534.1 APR
understand that lithe building does out currently have.tenant,that it Is my NEW RESIDEN-TIAL MECH. SQS-f.
resp.eability to really the occupant of the requirements which muatbe met CITY Ur CUrr'r+IIIVU
prior to Wua nee of a Certificate of Occupancy. V
Owner or aulhorlmd agent Date
TOTAL:
OFFICE COPY