24265 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMIT N�4 2 6 5
Building Addrees: _
IM70 tri4a ! eat 6L (art
nere a one A A
nr Ll Y) - 0,C_9- .7_ CITY OF CUPERTINO-BUILDING DIVISION h
c to nen f/ /{ 1ue.Ne: APPLICATION / PERMIT lJ ✓� Z
o�✓d- ✓� BUILDINGQ,ECTRICA4PLUMBINGMECHAMCAL CATEGORY CONTROL N
Architect/Engloser. Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ Li '❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am Ifermad under provisions of Chapter9(mmmenc APPLIANCESRESIDENTIAL JOB DESCRNTI N
Iogwith Sed1on7000)of Divlslon3 ofthe Buslnessand Pro/esslonaCede,and my �x
license le in full force and effect. tt�1 p PANELS !VI 0 F a
License Cla k.pq[J.0/7�! t V
Date Cmdrxd S( LY)i j UP TO 2DOAMIS
ARCHITECPS DECLARATION / 201.7000 AMPS
q�q�vv orO ZpC ]undemland my plaashallbeusedapubllcremrds. OVERIOOOAMPS r SQ.FT.FLOOR AREA S/SQ.Fr.
tj Llmnscd Pro(essenai SIGNS ELECTRICAL IMIALED
<Qw OWNER.BUILDECLARATION DER
IJn &ISPECIALCIRCUIT/MISC
i.., IhercNm
byarthatlam exempt fmmthe Contradori Llrenee law far the
following....(SecHon 7031.5,Buslmasand Profession Code:Anycityor TEMP METfROR POLE INST.
C 1" muntywhochrequoresapernr ttommtr d,alter,lmpmvedemolbh,orrepair
g'� APPTER
anydmdum prior to its Issuance,also requirmthe applicant for such permit to POWER DEVICES DA / I` �J
15 file a signed statement that he h licensed pursuant to the provisions of the G.w
3 u,� Contractor.License Law(Chapter 9(commencing with Section 7099)of Divi- SWIMMING POOL ELECTRIC
k,5, sion3ofthe BusnessandPro(essioaCode)orthathelsexempttherefmmand VALUATION
�.' the baste for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCIiESHXTURFS
O applicant fora pernitsubjectatheapplicaotto anvil perultyofnct mamthan ` n��. .._�
Q flue I,as ed owner of
he pr. SQ.F RIES TYPE CONSTRUCTION
S7 u, NEW RESIDENTIAL ELCCTR IT,
til �n ❑I,asownerll theproperty,orhesemployees with wages flair sole
c le(Sac tion,BUSd E13 andothe Pr and thesC de;The C ntractintenr or License
d for
Law
O sale(Sec apply to alnow and f property
Code:The ds or impdors Llceae Law
$� whoddoes oespplylaakhin erthphhlsonemplaim,pvess ideereon,and OCC.GROUP RIS.UNITS
p. whodoeaeuchwenotIntended orwgh hiaowale.lI oveverthebuildtsuch
Improvementsarenaintended earofco torsion.If,,ower-b ilderwdingve TOTAL:
Improvement Vsold within oneyearo(compldlon,theowner-bullderwili have
tFg.�urden of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE pIpOD IDNE APN
u L as owner of the property,am exclusively contracting with Bernard PERMIT ISSUANCE 1`/
mntradon to construct the project(Sec.7004,Business and Professions Code: lv
The Contractor's Llmnm Law dm nor apply to an owner of property who ALTER-DRAIN kVENT-WATER(FA)
Wilda or Improves thereon,and who,contracts for such p(Djeds with a
gqR6It[{'ador(s)licensed pursuant to the Contractor's License Law. FEE SUMMARY
c 5I am exempt under Sec. BACK FLOW PROTECT.DEVICE OUTSIDE FEES
B h P C for this mason
•
er Date
DRAINS.FLOOR ROOF,AREA,COND. SANITARY . Y N_Own
WORKMAN COMPENSATION DECLARATION RECEIPT#FIXTURES PER TRAP SCHOOL fAX Y N_
I hereby affirm that I have•ceu rar ce
of consent to self-thee,ora RECEIPT#
certificate of Workers' wa
'Comper
ntlonlurance ora rtl(kd copy,thereof/sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,LabC 330'%�-- RDC FTPTa
Com env GAS.EA.SYSTEM-OVER 4(EA)
BUILDING DIV]SION PEES
Ce ed wpybhereby lurnlahed. GREASE/NDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
ertl0ed copy V(sled with the dty lapnction division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
' COMPENSATION INSURANCE SEWER.SANTTARY-STORM EA 20OFT Date Recei tN
(Thos section need net be completed I the permit Vloroso hundred dollars
($100)oWATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Icertify certify that In the performance ofthework tarwhlch this permit is Lsueed, —
I shall not employ any person in any manner so a to become wbjed to the WAT02 SYSTI?)M/TREATING .
Workers'Compenaatlon Laws of Gllfomla.Data PAID
Z Z AppOcant Date Recei tN
Z O NOTICE TO APPLICANT:If,after mak)ng this Certificate of Exemption,you NEW RESIDENTIAL PLMB. '.IJFT.
Hshould Become subject to the Workers'Comperealion provisions ofthe Labor TOTAL:
N Code,you mustforthwlth comply wlthsuch proWooa orchis permllehall he
W j deemed revoked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a f] Ihereby affirm that there is a construction lending agency for the perform ELECTRIC FEE
7 Z' ince ofthe..,k for which this permit is Uaueci(Sec.3097,C1V.C.) TOTAL:
U O Lenders Name PLUMBING FEE J
LL H (coders Address QTY. 'MECHANICAL PERMIT FEE .MECHANICAL PBG.
O W Icerllfythatlhavereadthisapplicatoonandstatethattheaboveinformation
Iemmd.I agree to comply withal)city and muntyordinancesand statelaws PERMIT ISSUANCE FEESPAID:
). a relating to building comtrudion,and hereby authorlre representatives of this
Zcity to enter upon the above.mentionexi property for inspection purposes. ALTER OR ADD TO MECH. Date ReCei t#
V _ (We)agree to ave,Indemnify an d keep harMea the City oI Cupertino - - P
against liabilities,Judgment.,onea.nd expenses which may in anywayaceme AIR HANDLING UNIT(TO 10,000 CPM) S L,
age a icy In conseque or anting o(thls permit. CONSTRU
AIRHANDLING UNIT(OVER 10,000CFM) () )
S reo Ap
c rdd
raor Date EXIUUSTHODD(W/DUCT) CONSTRUCTION TAX PAID:
7171HA RDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle havardoua HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date Reuel tM
I ealth and Safety Code Section 25532(1)7 - HPATWG UNIT(OVER 100,00)BTU) TOTAL: 1
❑Ye. r No
Will theapplicant or Lure buildingedupantuseequipmentordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havanlous air contaminants as defined by the Bay Arca Air
• a lality Management District? BOILER-COMP OM'OR 100,000 BTU)
4 Yee No U LV
haveread Health
a et maledab requiremenh5533 aChapter. 1 of BOILER-COMP(OVER I(p,OBI BTU)
fisc Californiadsrd
Health building
Code,Sedloa75505,255.3and25574. I
understand that ithe buie..pdoes not a rrentlyhave a tenant,that if met NEW RESIDENTIAL#CCH. SQ.I7. NOV 12 1992
responsibilitytIssuance
of a theoccupantoftherequircrmntawhich mustMmet saL
prior to Lasuance cafe Certificate o(Occvpancy. '
CITY Ur (;Ur-'T La .
Owner or authoriced agent Date ISSUED BY
Q
TOTAL:
OFFICE COPY .