23078 (4) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification PERMITNO.
Building Address:7 72-9 � A , l -3 _ LOT
a�� r 2 3 0 7 8
w ars ams: LIME 7 •—f✓hone; ��1 - G 7VS
L 973 4.? CITY OF CUPERTINO-BUILDING DIVISION
contranorsNa / / _7Lk.No: APPLICATION / PERMIT
LNNS ) BUILDING-ELECTRICAL-PL BW M HAMCAL CATEGORY CO OI.
rehitact/En ns, Lk.No:
�SD�' • - BUILDING PERMIT INFO
s
CITY ELECTRIC PE T FEE
Address: PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Ihereby
actionaffirm that lrmllcmcedunder provisions of Chapter
ssions9de,and e- AI'I'LIANCISRE C L JOB DESCRIPTION
Inense1Section form
IarofenloneC.ds,,and my
Iittnre la in fu0(ortx and effect. PANELS 5 FDw L
DataLi. Ckm L1e a
Date Contactor
ARCHITECTS DECLARATION 1-1
q�v ree O I understand my plans shall be used as public mmrds. O ER PS SQ.FT.FLOOR AREA S/SQ.aFaT�.
Fi� Licensed Profenional 1 9 ELECTRI L �2 r\
G�6
tq5 5o V< OWNERBUI,LDER DECLARATION
mthal l amefrom ctorb License Law for the
SPRCIALCIRCUI
Z2- following reseenn.(SMlon 7831.5,Business and Professions Code:Any city or P.METFROFttywhich requimsa permktomretmct,alter,Improve,demoll-h,orrcpalr
anystmmpHortolauanceamquietheappBcatforsuchpemtto
fl.knST
✓��� I--aIr/_IJA
�v
a signed statement that he Is licensed puns..to the proaltors of the POWER DEVICES
O6 Contractor's License Law(Chapter9(on.aragwithSection 7000)o(Dlvi-
�OS al3 ofthe Business,and Professions Code)orthat he is exempt therefromand SWIMMING POOL fl.E RIC
onVALUATION
the beak for the permit
alleged u exemption. Any violation of Section nor m re any t•'1_ a� � ' .a�
p appllwntfor a perMt eubjecta the applicant toe civil penalty of cart more than OUTLETSSWITCHFSH%TUItIS -�(J �./
five hundred dollars 050M. NEW RESIDENTIAL ELECTR
❑I,as owner of the ro —SQFL STORIES TYPECONSfRUCTION
p perty,or my employees with wage;as,thele sok `O�
Ula .1a(S
compensation B.,menheworkefosakeaBucte:TheC ntract r'orcense far
5�O dile lnot 7064,to an ow and Prooperty Code.The Contractor;License law -
j .$ does whodotapply torn unser ofp rcxugh who nempor impmvnted eem,that and
as^ whodoeeauchwork himself orthroughhbownempinryeea,providedthalwch OCC.GROUT' RIS.UNITS
Improvements arc not Intended oroffcrcd forme,If,however,thebullding or 7
Improvement ksold withinoneyearofcompiMiomtheowner-buRderwlll have
tFkJ)urden of proving that he did not build or improve for purpose of sale.). QTy. PLUMBINGPERMIT FEE FLO55 ZONE APN
Lf L as..or of the property,am exclusively contra th llcam ci pp�fyp ISSUANCE
contractors to construct the project(Sec 7044,Business d Profen ode:
Its Contractor';License law don not apply to w a lir f property ALTER-DRAIN k VENT.WATER(EA)
Wilds or Impnones threaten,and who contracts for such pne=with a -
cgp�actorWheensedpursuamtothe Contractors) ..Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ 1 am exempt under Sec. B P C for this mown
s.^.F4• - SANITARY Y_ N_
= OUTS!Up FEES
7 Owner p e D NS FLOOR ROOF,AREA,COND. RFCEIPf p
WORKMANCOMPQJSATIOND LARATION D PERTRAP SCHOOL TA% Y_ N_
QI hereby affirm that I have a ttrtlB ata of at,.
to eel(-Insure ore RECEIPT M
cenRou.17Wor1m Cmrpereattanlreurantt a certified copy thereof(Sec. G FA. INC,I OUTLETS PARR FEE V N
3800,Lab C) lz�
Policy p RECEIPT M
Com any FA -0VER4(FA) BUILDING DIVISION FEES
�CertlOed copy b hereby form-heciSE/ DUSTRL WASTE INTERCEPTOR PLA ECK FF�E eO
OCembdi copy V flkd wBh the Inspection division. \
CERTIFICATEOPE% PTIONFROM WORKE GREAS ?RNs pA
COMPENS TION INSURANCE S SANITARY
(This section need not be comp) ediflhepermlt is for.nehunden doll; STORM EA.200FT. ,-y,-, —Remi t#
(81 W)orlenJ WA HFATERW/VENT/ELECTR EN� •EE Y N� �
IcertBythat Mthe peAormance the work(or which tNs it I. e v 6
1 shallnot employ any person m an caact..to bpct
Workers'Compensation laws of Calif. Date W TERSYSI79N/TREATING PAID
O Z Applicant [�
Z O NOTICETO APPLICANT:If,after aWnglhls rtlfeem of c plWn,you RESIDENTIAL PLMB, SQ.FT. Date #
m .l
F should become subject to the Workrs
ers''Compeat provisio of the Labor TOTAL
WW Code,you mu at forthwith complyk withsuch provisrthlspermitahallbe BUILDINGY
j deemed revoked.
W
CONSTRUCTION o:V LENDING AGw SEISMIC FEE
Ihercbyafftrmthat thereem kacowtroctlon lending agency the perform- ELECTRIC FEE
C) Z aam.f the work for which this permit is issued(Sec.3W,Civ. T ��
U O Tender';Name PLUMBING FEE
LL H Leadcre Addreaa QTY. MECHANICAL PERMIT TEE MECHANICAL FEE
O W lmdifythatlhaversadthbrpplimtlonandstatethatthe above ln(omou.n
Ismmct.l agree to complywith all city and county ordinances and state law; PERMIT ISSUANCE FEES PAID:
2
U) relating to building construction,and hereby authomm representatives of this
F city to enter upon the above-mentioned property for inspection pu rpmes. ALTER OR ADD TO MRCH.
(We)agree to save,indecently an d keep harMess the City of Cupertino Date Receipt#
V agairmt habllitles' gments,m&saad expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agalnet said Cl n Bence ofthegra ntl ofthieparmit.
I-X-131 AIR HANDLING IINTT(OVER IO,WOCFM) CONSTRUCTIONTAX V
rcof Applicant/Contractor Date D(HAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUSMATEBIALSDISCL RE
Will theappBcant or future building occupant-tore or andls hazardous HEATING UNIT(TO 100,000 B'rU) Date Rec '
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the -
I With and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,"BTU) `
❑ Yes M No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP OMP OR 100,0(10 BTU)
4 Yes n No
have madtheh. �omaterlalarequimm ntsunderChapler6.95of BOILER-COMP(OVER 1W,OW BN)
the Califemla Health A SafetyCode,Sertiona 25505,25533 and 25536.1 LLJ'
xx(ty' understand that lithe building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.IT. r 2
responsibility to notify the occupant of the requirements which at be met '^
prior to lssua am of a Certificate of Occu pa nay. AIV 6 1993
Owner or authorised agent pate �I Y Vr
I ISSUED BY:_
—4
OFFICE COPY