23154 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Buildin Project Identification PERh0TNO.
Bui�aing Addrea,: 1tr ` 2 3154.. jokS i.�oc_s.WOOC b+- . �. c�7M 9 cA. QSD/Y
Owners Name: one: APPLICATI07097177=A
L L4L M. b,,-�\ CITY OF CUPERTINOQBUILDING DIVISION
contrartoraName: LIc.No: APPLICATION I PERMIT
I L Oh 617$391 BNLDING-D.ECTRICAI.PLUMBINGMECI IAMCAL CATEGORY CONTROL Is
Archit /Engineer: Lic.No:
�O L 077 QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO .
Add.. �Y,3 FdsA l/' �.✓ PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACT 'S DECLARATION
Ihereby
ectionrm that lamlfce3oftheunder pessandof Cssions9(commenc- APPLIANCFSRESIDENTIAL - tr,u p� Og�rr ltd'
bear.ingwith infion70D3)andefeon3o(the Buslnes,and ProfesslonsCode,and my W !l''''"'�`', c777{{{eJ'��'� {Jv
license la In fu8 farce and effect. PANES
Cla
D
Dateto w 6Corintractor Ir
ARCHITECT'S DECLARATION 201-IODDAMPS
$/
rc0 Z I understand my platy shag be used a public records. OVER 1 1 SQ.FT.FLOOR AREA F,(j.FT.
iWO SIGNS EL C
Licensed Prvlessional
<N OWNER-BUILDER DECLARATION SP�lAL
t- Z Thereby affirm that l am exempt from the Contractor's License Law for the
Z O
OZI-..a fo8owing reason.(Section 7071.5,Business and Professions Code:Any city or `
TEMP.M EINSf.
countywhich rcqubes a Pxmtit lomnstmct,alter,bnprove,demolbh,or repair
anysbuclum price to its =ince,,Lao requirealheappecam for such permit to POWER DEVICES
p-V file a signed statement that he is licensed pursuant to the provisions of the
qq Contractor's License Law(Cha r9(mmmencin 'wilh Section 7000)of Divi- VALUATI
He, sion3ofthe Business and ProfesssonsCode)orthatt he is exempt thercfromand
SWIMMING IDOL ELECTRIC
5 i�O O the basisfor the alleged exemption. Any violation of Section 7031.5 by any OUTI.ETSSWITCHESFXfURFS
applicant fora permit subjects the applicant to a civil penalty of not morethan
o `~ five hundred dollvs C$S00).
m NEW RESIDENTIAL ELECTRSQ.FT. SfOWFS TYPE CONSTRUCTION
❑I,as owner of the property,or my employees with wages as their sole
compensation,weldothe work,andthestructum b not intended or offered for
5 0 sale(Sec.7046,Business and Professions Code:The Contractor's Lt..law
does not apply to an owner of property who Wilds or improves thereon,and
F$^ whodoessuch work himself orthrough hisownemployees,provided thalsuch OCC.GROUP RFS.UNTfS
Improvements are not Intended muflered for sale.I(however,thebuilding er TOTAL:
impmvementbsoldwithinomyearofcomple ioMtheowner-builderwlllhave
me_�urden of pmvmg that he did notbuudorlmproveforpurposeofsab.). QTY. PLUMBING PERMIT FEE
u FLOODZONE APN
I,as owner of the property,am exclusively Rusy ess andang with Rinsed PERMIT ISSUANCE
contractors to ro Liven the project(Sec.apply
Business and Pf property
Code:
The Contractor's o es then Law don not apply tct an owner of property who ALTER-DRAIN&VENT-WAhR CEA)
Wildsra improves thereon, and who contracts !I.such p(ojecb with a FEE SUMMARY
mtractorexemre under Sint tothe Contna[or'sLicense Law. BACK FLOW PROTECT.DEVICE
L�I am exempt under Sec B&P C for this reason
a
DRAINS.FLOOR ROOF,AREA,GOND. SANITARY Y N—
Owner Date RFLFIPI'M
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOLTAX Y_ N_
❑I hereby affirm that I have a certificate of consent to self-Insure,or a
t mrtificateofWorkera CompensatiolT rnmoramrtlfWmpyther f6ec. CAS F.A.SYSTF7.1.11NC.d OUTLETS PARK FFP YECEPN9
3800,Lab C.) —
Po11cy Js RECEPf s
GAS EA.SYSTEM-OVER d(FA)
Co any BUILDING DIVISION FEES
�Certlfied mpybhereby fumbhed. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WOR KERS' GREASE TRAP PAID
COMPENSATION INSURANCE
( SEWER-SANITARY-STORM EA.200FT. Date Recei [#
fhisaection need not be complard if the permitis forum hundred dollars
I$100)eriess.) ENERGYFEE Y N
Iirtifythatldtfie per(ormani of thewrnklor which this penult is towed, WATER HEATER W/Need/ELECTR —
I shall not employ any person In any manner so as to become subject to the WATIX S)'S[TM/TREATING
Workers Compensation Laws of Cs Wornb. Date PAID
O Z Applicant NEW RESIDENTIAL('LMB. SQFT. Data Recei t#
Z O NOTICE TO APPLICANT:ILaftar making this Cefi(Ioteof Fiemptbn,you
should became subject to the Worlcm'C°mperuation pno lons of the Labor TOTAL:
N Code,you must forthwith comply with such provisions orthis permit shall be
W > deemed revekea. BUILDING FEE
W — CONSTRUCTION LENDING AGDVCY SEISMIC FEE
IL E5 1herebyafRrmthat there is a construction lending agency for perforrm ELECTRIC FEE
:) Zan.of the work for which this permit is issued(Sec.3097,Civ.C.) NOTAL:
00 Lorder'aName PLUMBING FEE
LL F Lender'spdareas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW (certify theft have read thisapplicatlon and statethattheabove Information
M face=&.lagmetocomplywithalldtyand county ordinances and statelaws PERMIT ISSUANCE FEES PAID:
relating tobullding construction,and hereby authorize representatives of this
Zcity to enter upon the abovementioned property for Inspection purposes. ALTERORADDTOMECH. Date Recal t#
— (We)agree to save,indemnify an d keep harmless the City of Cupertino P
against liabilities,pdgment%costs and expenses which may In any wayacerme AIR HANDLING UNIT(TO 10,W)CFM) SUBTOTAL:
againsts ' sty in consequence of the gran of fhb permit AIR HANDLING UNIT(OVER 10,000 CIM) CONSTRUCTION TAX
altife Z r
of Applicant/Contrsttor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
r-nVill the applicant or future building occupant store or handle hazardous BEATING UNIT 100,000 BTU) Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
I lealth and Safety Code�+.Li
25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL.
F1 yea u No
Will the applicant orfuture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISS1f' %(,ZEfiTl6,TE
which emit hawrdous air contaminants as defined by the Bay Area Air `V`-•i-. Y"L
• Qu a lity his rogement Dnistnctt BOILER-COMP DFP ORIM,00)BTU)
4hY29 "° 'JAN 02 1992
averead t &Sa Tet materials tions 2menb5533 and 255r6.95 o! BOILER-COMP 100,000 BTU)
the California at if the Health&Safety Code,Sections 25505,have.t and 25534. I
resporunderstandtbatnotify, the occupaning doast
note currentlyrequirmnts which that b iset NEW RESIDENTIAL MEGs. SQ.IT.
raor touuanc ofaC Certificate
Occupa requirements which must be met G17Y Ur 1aUF'cnllla%"1
Prior to Issuance cats Ceniticate of Occupancy.
Owner or aulhorived agent Data ISSIIED BY
TOTAL:
OFFICE COPY