19555 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bundin Protect Identification a - PFRMITNO.
Sodding Address: _Z OC2 ; `]:- cv
V _r -.... � 19.555
era ams: e. _ ,-.. CPfetSG'RdABDBEifRALISE'i
nCITY OF CUPERTINO-BUILDING DIVISIONas 7A Me .—, pIT 0
Contractor's Name: L7. o: APPLICATION /PERMIT.
- -�— �—L —
Architect/En neer. L No BUILDING-ELFJCTRICAIIPLUMBINCMrCI NICAL CATEGORY CONTROL X�y C
&�. (� •1u. t.:.n ,.` i,t BUILDING'PERMIT INFO,'. • 'd.
ELECTRIC PERMIT • FCC -
Address: PERMITISSUANCE ❑ ❑ ❑
If
LICENSED CONTRunder SDECLARA 1
Ihereby
actionrmthal Dtvisiam ensed 3ofthe ustnemslonsoffenion Code,and rn.my APPLIANCFSRESIDEMIAL JOR DPSCWPTfON
Ing if vol ict1on70f1D)ofd effeon3o(Ihe BualnepeaantlProfeeslonsCode,and my /"��'y� yy�
Lirenso C6ss B fo and LE,effect.. / .. PANELS CIJI I 1 1/111
Date9_3 Contractor ",1,
ARCHITECTS DECLARATION 201-IM AMTS -
po!0NzI understand my plans shall be,used as public records. OVER1000AMPS SQ.FT.FLOOR AREA $/SQ.FT.
E () Licensed Prolessbwl SIGNSELFOTRICAL
6G7 OWNER-BUILDER DECLARATION
a�
�I � IhercbyalRrmthatlam exempt tmmthe ContraRor'e License hwfor the SPECIAL CIRCUIT/MISC
i'Z ❑ (olowing reason.(Sedlon 70315,Business and Profeasbna Code:Any tlty or
county which requires.permit romnstrun,alter,Improve,dernolhh,or repair TEMP.ME ROR POLE INST.
E anystmcture Inform its Issuance,also requiresthe appliont for such permit to
r file a signed statement that he Is heresed pursuant to the provhloru of the POWER DEVICES _
��gSjO Cont.a.e.License Law(Cha er9(commendn mthSed1on7000)ofDlvl-
[il�c''rn B SWIMMING POOL II. CfRIC
O slon3ofthe Business and Prolessloru Code)orthat hehexem there(romand VALUATION
I. O the bash for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS XTUR [H
applicant for a permit subjects the applicant to a civil penalty of not more than .J�
�Aj flue hundreWos of thepr. SQ STOIIIES SVFG CQNSTRUCTION
NEW RGSIDENTI L GL� Ff.
GGG111 ti '
�n ❑1,as o of the property,or and he employees with wages r their sale
1A A
cola(Se. 0KBusinessl do workefeade,Code: hnm Intended or offeredfar
doe(net apply
to a now owner
f property who
Wilds or imporms Lirewe Law
$$ does not apply to an owner of property who n Wilds to Improbes thereon,a OCC.GROUP RES.UNITS
EE whodocesuchworkhimsel(orthmugh hbawnemptoyees,provided that sue
Improvements are not intended oroffered lwsale.I(howevegthe bulltling or ,TO'p : /7
ImprovementhsoldwlthlnoneyearofcompldloM1the owner-bullderwlll have `-
t"rdenofpmving that he did not build m improve for purpou o(sale.). Q� t�;l � • ,PE MIT.' +' '.�1` 'E�' FLOOD ZONE APN �—
u L as owner of the property,am exclusively mnlraRing with Ilrenaed ,
contractors to condruct the projed(See.70fy Business and Professions Code: i
The Contractor's License law don not apply to an owner of property who IAht SSUANCE. 3s-ll
Wilds or Improves therms, and who contracts fw such pto)ecra with a AL RAIN& -WA _ 3
e 11.[.0 (a)Ilnnaedpunuanttothe Contractor's License Law. ilk`"u�,i ll'4+°$FEE SUMMARY"+`� �+I,
u I am exempGureason,der Sec. B&P C for this ren BA FLOW T T.DOUTSI DE FEES
EftOwner Date
NS ROOF,A CO SANITARY Y_ N- RFCpR.pp
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAX Y N
❑1 hereby aflleei that 1 have o Insurance
of consent m upythsare,or a RECEPT p
3udif800,1cateot Worken'Compematlan lnsuranrn oracertltled copythereot(Bee: GAS EA.SYSTEM-11NC.4 FTS PARK I72 .Y N
3$00,Lab C.) •RECEFT B
Policy p - GAS EA.SYSTEM-OVER4(EA)
Cu any - BUILDING DIVISION FEES
�Certifed copy is herebyth the
CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy hfiled with the city lmpection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER.SANITARY-STORM EA.200FT. Date Ret:ei t#
(Thhscdion need not Mcomple[ed lithe Permit hundred dollars P
($100)or less') WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I certify that in the pertormenmof the work for which this permit is issued, I
I shall not employ any person to any manner on as to become subject to the WATER SYSTEM/TREATING _J
Worker:Compensation Laws of California. Date PAID J=1—
0 Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Remi t#
Z O NOTICE TO APPLICANT:ILaRer making this CertBlrate of Exemption,you
should become subrd to the Workeri Compensation provisions of the Labor TOTAL:
Ln Cod,You at forthwith comply wlthsuch poevhlomarthh permit shall be - I FEEW ] deemed revoked.
CONSTRUCTION LENDING AGENCY - SEISMIC FEE
Il IhcmbyafBrm that there is a coestmdlon lending agency for the perform ELECTRICFEE
7 0 anceoftheworkforwhichthhp.r t/ sued(Sec.3097,CIv.C.) TOTAL:
U Lenders Name - - -, PLUMBING FEE
H Loodere Address QTY
- -: MECHANICAL PERMIT EE;,
LL - .FMECHANICAL FEE
0 Ed 1 is cormd.Iagreetocomply with allcttyand county ordinances and nate lawn PFRMITISSUANCE FEES PAID:
�. relating to building construction,and hereby authorize representatives of this
N - city to enter It Pon the above-mentioned property for inspedlon purposes, ALITRORADDTOMM-1. '
Z (We)agree to save,Indemnify an d keep harMess the City of Cupertino Date Receipt#
V• against labNties,judgments,pcos�ta(a{nyd expenses which may In anyway acme MR BANDUNG UNIT(T010,(00 CFM) SUBTOTAL:
again said City in cons 6 _g of this permit. AIR HANDLE NO UNIT(OVER 10,000 CFM) CONSTRUCTION TAX F,\),
�[S�Ya`h P-/Y f o
Signature of Applicant/Contractor - 'Date EXI EAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fiat.m wilding occupantstore or handle havrdous HEATING UMTCM 100,000 BTU) Date RCCei t# _
material as defined by the Cupertino MuNdpal Code,Chapter 9d$and the
Health and Safety Codon 25532(.)7 HEATING UNIT(OVER 100,0(0 BTW TOTAL:
❑ Yes No
Will the applicant I m building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contandnants as defined by the Bay Area Air
Quality Management��,ykt7 BOILER-COMP pTIPOR l00,IX0 BTW
�ycs
X.
have read the hazy us materials rcqulrcmenb underCIns Enter 6.95 of BOILCRC'OMP(OVQR 100,000 BTU) •/
the Califernia Health&Safety Code,Sedlom 25505,25533 and 75534. 1 +J 1 4 1990
understand that ifthe buildingdcea not mrrently have alemnL that ithmy NEW RESIDENTIAL MECI{. 1.7p
i.. - reepon. bllitytonotilythee, oftherequireme awhich muatbe met
prior to uance ofa rtifl o ccvpanry.
{� � an
Own aut razed ag t Date _ TOTALISSUED BY: V1•r�`-z
OFFICE COPY
h Gt of Cupertino
` 410300 Torre'Avenue r ,i t v< ' „ rt q' +'� !"` P.O Box 580
' Cupertino.CA 95014-3255'.- kY'� ',r R r 1, lyy,y Cupertino CA 95015 0580. -
-_Telephone: (408)252-4505-
`FAX: (408j:252-0753 t^F.•. �,!_4 "r.�. +tr :/ •y 13.'x% -
COMMUNITY
DEVELOPMENT -
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