23907 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Pro'ert Identification PLRMITNO.
Building Address: to V s ? 9w 23907
• nerd ams: one: APPLICATION SUBMITTAL DKTr
L Q D CITY OF CUPERTINO-BUILDING DIVISION
Co t.d.e.�Namye�:�� Ic.Nn: APPLICATION 1 PERMIT
_lLe";7-- �r BUILDING-ELECTRICAL-PLUMBINGMECHANICAL CATEGORY CONTROL
rchlteci/Engineer. Lle.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrcsc PERMIT ISSUANCE ❑ ❑ 1:1LICENSED CONTRACTOR'S DECLARATION
I hereby Mm3ofunderpmsandsolenionsr9de,and c- APPLIANCES-RESIDENTIAL JOB DFSCRB'170N
inense1Secikn7000)otdofelon3 ofthe BualneseandProtessloneCade,anal my a�d m ye ` 11-4
4' er_
license b In(u and dreg. PANELS 717 .r.7• r la.(
Lkan Gkas Lice h f W
Date Conlncior l✓t
ARCHITECT`SDE public OVER00AMI'S
Q CO I understand my pbrs a1uB he used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA f/SQ.FT.
d(/ Licensed Professional SIGNSELECTRICAL hee � I ^�
�6 OWNER-BOLDER DECLARATION $pEC1AL CBiCU17/MISE `J
Ze., Ireby.fil.that l am exempt fromlhe Contractor's License Law fon the - t
oo pppp following reason.(Section 70'31.5,Business and Profnslona Code:Ancityor _71 � \ �(] � ' 7 i
FZ^� c.eywhich requiessa pormgtocowtruc;alter,improve,demolleh,orreair �p'METMORPOLEINST. �J ✓I V
anystmmm prlorto its issuance,also requiresthe applicant forauch perrtdtto 0
OPOWER DEVICES
/ �+file a signed statement that he is licensed pursuant to the provisions of the F/ 7
w Contractor's Llcerse Lew(Chapier9
El (commencingwithSectkn7000)ofDlvi-
Pion 3 ofthe Buelnessand Professions Code)orthat he k exempt therefromana SWIMMING POOL ELECTRIC ry`
the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS SWITCHES-FIXTURES
{a0Q•T
applicant fare permit subjects the applicant to a civil penityo(nw nnrethan
flv�u as ne" ,0,theed dollars 00). NEWRFSIDFIMALELECTR SQ.FT, STORIES TYPE CONSTRUCTION
GG����jlljjj �n Lasowner l of property,orhe employeeswithwages their sole
< compensation,svBlaothework.andthes Code:Thee is Contactoran Intended or License
d for
Law
O sole Cr..appl04Cy
to an o s owner
Prolerbro Code:The Contractors hereat Law
$ don caw apply to an owner or property who n lids or improves thereon,and ch OCC.GROUP RES UNITS
improvements
minteVwlM1magh Msowne.If,ho eprovidedthatg or
Improvements are caw Intended varofred(orsak.If, caner-r,lheerlldingve TOTAL:
Improvement ksold withinoneycarofcomplwloMlheowner-builderwlll have
thiLtiurden of proving that he did net build or Improve fon purpose of We.). QTY. PLUMBING PERMIT FEE FLODDZDNE APN
L as owner of the property,am exclusively contracting with licensed PERMITISSUANCE
contractors to construct the project(Sea 7044,Huge.and Professions Code:
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN A VENT•WA1IIR(EA)
Wilds or Improves thereon, and who contracts for such pRajecia w!th a
cm1pet.,O)licensed pursuant to the Contractorslicense Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B k P C for this reasonOUTSIDEFECS
Owner DRAINS.FLOOR ROOF,AREA,CONI. SANITARY Y N_
' Date RpDplpp N
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCI{OOL TAX Y N
❑I hereby affirm that I have a certlBcate of consent to vel(-Insure,ora RECEIFT N
certlticateof,7Wod wComperuxRon Imunnceora certi(kd ropythereof(Sec. GAS FA.SYSIEM-]INC.IOUILE[S PARK FF7i Y N
pahcy'Lab_t'�rr�F�� 2/Z�70 /
poll M RECEIPT M
Com n_ CAS FA.SYSTEM-0VERd(FA)
f'�cY BUILDING DIVISION FENS
eninee pylaherebyththa ed. GREASE/INDUSIRLWASM INTERCEPTOR PLANCHECKFEE
Certified copy V llkd with lbe city IaspMlon allusion.
CERTIFICATE OF DfEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION hapern INSURANCE SEWER-SANITARY-STORM FA.200FT. Date Recei tN
(0)or lmtlon need caw becomplded If/he pamdt k for oro M1undmd dollars
(f101)wfy that
WATER HrAT.Et W/VENT./ELECTR ENERGY FEE Y N
(certify employ
any pehe rson
in anf tmannerhe work so as tobeco permit h Issued,the
I shall caw employ any person In any manner so as to seroma Pubject to the
Workcrs'Compensatlon laws o(Gk. WATER SYSTEM/TREATING California Date PAID
O Z Applicant Date Recet t#
Z Q NOTICE TO APPLICANT:ILafter ma king this Certificate.(Exemptbn,you NEW RLSIDINTTAL PLMB. SOFT.
should become seb)M to the Workers'Compersatlon provisions of the Labor TOTAL:
N
Code,you=at forthwith comply with such provisions orthla permit shall be
LU j deemed revoked. NGELE
LU
G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency for the pedomv ELECTRIC FEE
:3Z ance of the work for which this permit I,Loved(Sec.3097,CIv.C.) TOTAL
V O Icnder's Name PLUMBING FEE
LL f Icndcrs Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icenlfythatlhavereadthkapplica0onandstatelhattheabovelnlarmalan
0. brormd.I agree to complywith all city and county ordinances area state laws PERMIT ISSUANCE FEES PAID.
y relating to building construction,and hereby authorlu representatives of this F Z city to enter upon the above-mentloned property for inspection purposes. ALTER OR ADD TO MECH. Date Reeel tis
— (We)agree to save,IndemNfy an d keep harmless the City of Cupertino
against liabilities,judgments,coatsa xpenses which may in any wayaarue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL
agates CI idmns uence grantin this ennit. '
- AIR HANDLING UNIT(OVER 10,OWCFM) CONSTRUCTION TAX
gmtureof Applia
Hn erredSMATERIALS D allAUS'I HOOD(W/DUCT) CONSTRUCTION TAX PAID:
A RDOUDISCLOSURE
WIII tM1c applies orfuture building occupant store or he ed le hazardous HEATING UNIT HD 100,000 BTU) Date Recei tN
material as defircef by the Cupertino Murddpa l Code,Chapter 9.1 2,and the
Y. r]No
Ikalthand Safely Code Seciion25531(a)7 HEATING UNIT(OVER 700,000 BTO TOTAL:Ji
Q
I Illthe applicant or future Wilding occupant use equipment or devices VENDIATIONFAN(SINGLE RFSID) ISSUANCE DATE
which emit hazardous air mntaminantsas defined by the Bay Area Air
Quality Management District? BOILER-COMP DFB'DR 1W,IXq BTU) P p '
4 Yea No W
haverea, the
ealth& oety Codeialection requirements and under Chapter 2SS34.I of BOILER-COMP(OVER 100,000 BTU)
the errtandt Iteethek ildinCode, etcurs25505,veatand25536.I ne 9 1992
understand that hies the ocgdoea caw currently require enta hick that Rismy NEW RESIDENTIAL MECH. SQ,R j1Y� �,
rmporslBllity io notify the wcvpant.Utes requlrcmenb which moat be coli V
prior l0 issuance of a Certificate of Occupancy, M I IIV�
CII r UI- Gurc
Owner or authorlmd agent Data ISSUED.BY:
TOTAL:
OFFICE COPY