24200 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification , PERMITNq4
B4ildirrq Address: F7 A O O
J La'' 'N tvF. N q:5014;
G
s aces:- Phone: p g q p
neo 2 CITY OF CUPERTINO-BUILDING DIVISION
C.nlraches Name: Lic.No: APPLICATION I PERMIT '2 _9 2--
i, ' Architect/En - BURLDING-ELECTRICAI.PLUMBING-MECFIAMCAL CATEGORY CONTROL
gineer: Lit.No:
U�L—.SON
22407,3 BUILDING PERMIT INFO
QTY ELECTRICPERMIT `FEE
Address: PERMITISSUANCE �Q ❑ ❑ ❑ I
LICENSED CONTRACTOR'S DECLARATION LFI hereby affirm that am licensed under provisions of Chapter 9(mmmenc- APPLIANCESRESIDENTTAL JOB DESCRIPTION
ingwith Seodon7000)of DWIMoel ofthe BusinessandProfessloreCode,and my ax�a`.,y�t�.�p
license is in full form and effect. PANES L ' r J
License Class Lit.p , �I
Date Contractor
ARCHITECTS DECLARATION 201-1000AMP13
cc0 7 I understand my plana shag be used as public rerordx OVER 10D0 AMPSF MET R $/SQ.FT.
O
CCC¢ U Licensed Professiowl SIGNS ELECTRICAL �^�a ® p T
N 6 OWNER-BUILDER DECLARATION III!-, U 1
a Fn SpFG1ALCIRCIIIT/ML.0
i.., Z owing rgionnthat I ection exempt from the d Prithct.ra License Law fort he
7p
following reason,(Section 7mitto Business and Professions Code: h,or city it
OZH� TFMp.METER ORPOLE INST.
.q� countywhich requiresa permittomnstruct,Ater,Impious,demolish,orrepalr
a anystructure priona its issuance,also requiiestheapplicant forsuch peroutto POWER DEVICES 4.
E file a signed statement that he is licensed pursuant to the provisions of the
Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi-
O SWIMhIING POOL ELECTRIC
F,
vi, scan basis fo the elle a dprofessions Any)violation is exemptte�fMI-5 by and VALllATbIF
¢5 the basis for the alleged exemption. Any violation of Section not room
m any OUTLE'ISSWITCFIES,FIXTURES
applicant for a permit subjects the appgcantt0 a civil penalty of not more than
c o O five hundred dollars he pr.:
�GroW'' NEW RESIDENTIAL ELECTR •SQ.FC. STORIES TYPE CONSTRUCTION
..�n ❑I,as owner of the property,or my employees with wages r their sole
C7¢ compensation,Business
uldessandhe Professions
e; is The Contractors
orofferedLw
5 ❑
sale(Sec.apply
Bu sinessandf property Cad e:The Contractor's Licewe Law
does not apply to an owner of property who builds or improves thereon,and OCG GROUP RFS.UNITS
1 a whodoes such work himaegorthrough his own employees,provided that such ,
improvements are not intended motioned for sale.I(however,thebuilding or y TOTAL:
improvement issold withinoneyearolcompletion,theowner-bugderwill have ,
thecon rdenolpmving that he did not build or imp rove for purpose of sale.). QTY, PLUMBING PERMIT' FEE. FLOOD ZONE APN
L as owner of the property,am exclusively contracting with If_ d PERMIT ISSUANCE
etois l0 c.rtstrvct the project(Sec.7046,Business and Professlora Code:
The C.ntnct.r's License Law does nM apply m an owner of property who ALTER-DRAIN EN
&VENT-WATER(
Wilds or Improves thereon,and who contracts for such pto)em with a .- -
co,➢tt�[ctoKs)Emitted pursuant to the Contradors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY'
LJ I am exempt under Sec B&P C for this reason
OUTS I DE FEE 5
DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y_ N _
Owner Date - RECFII''1'p
WORKMAN COMPENSATION DECLARATION �.���.�P SCI{OOL TAX Y_
ceN_
[-It hereby affirm that I have certificate of consent toopy teRECEIPT p
rtificateC(WOrkers'C.mperaatlo copy Insurance or thereof(Sec.
3800,Lab CJ GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y_ N_
'
' �
RECEIPT N
itoRcy a GAS EA.SYSTEM-OVER
Cam any
O Certified ropy U filed withh tthe M- 4(EA) BUILDING DIVISION FEES
Certified ropy b herebytd. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
he city
tlty Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' - CREASE TRAP PAID
COMPENSATIONINSURANCE. SEWER-SANITARY-STORM EA.2gwT. Date Recei [#
(rhissedion need not W completed if the permit is forone hundred dollars
($100)or less.) 1, WATER I{FATFli W/VIM/dECTR ENERGY FEE' Y N
I certify that in the performance of the work for which this Arno t is Issued,
I shall not employ any person in any manner so'as to become subject to the WATER SYSTEM/TREATING
Workem'Compensation Laws of California. Date '" PAID
z Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date ReCei #
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should be..subject to the Workers'Compensation provisions ofthe Labor - TOTA t
F W Code,you most forthwith comply with such provisions orthis permit shall be —/�
LU j deemed revoked. - BUILDING FEE
Il.j — CONSTRUCTION LENDING AGENCY - SEISMIC FEE
dIhereby affirm that there isacoratrvction lending agency for the perform r TOTAL: ELECTRIC
0 ance of the work for which this permit is issued(Sec 3097,Civ.C.)
U _ lenders Name PLUMBIN
LL r LendersAdderas QTY. MECHANICAL PERMIT FEE ME L FE
U I rertilythat l have read this applicatlonand nate that the above Information
O W isrorrect.l agmeto comply with all city and munty ordinsame and nate paws PERMIT ISSUANCE, F SP D:
r W relating to building construction,and hereby authorize representatives.!this ALTER OR ADD TO MECH.
H Z dtyroenter upon thetab.ve-mentioned property for irapectmn purposes Dale Receipt#
(We)agree to save,indemnify and keep harmless the City of Cup Im
V agai liabil s,judgments,roes and expenses which may In nywa came AIR HANDLING UNIT(T010,000CFM) - SUBTOTAL:
agai i en fthe granting.!th(sye ,AIRHANDLINGUNRroVER10,000 CFM) CONSTRU ON TAX
gnatur of Applicant retractor II ate EXHAUs'THOOD(W/DUG17 - CONSTRUCTI NTAX PAID:
HAMR DOUS MATERIALS DISCLOSUR
Will the applicant orfuture building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) - Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Se Section 25532(a)? HEATING UNIT(OVER l 00,000 BTU) OTARN
afety Cod
❑Yes . N NO
Will the applicant orfuturebuilding ocmpantuse equipment ordevires VENIILATION FAN(SINGLE RFSTD) ISSUANC DATE
which emt hazardous air oontaminantsas defined bythe Bay Area Air
Quality Management T i❑❑sMct? BOILER-COMP f3FR'OR 100,000 BTU) ®
E haveread the hazar Numaterods requirements under Chapter 6.95 of BOILER-COMP(OVM IDgA 000 BTU) P D '
(he lifmia Health&SafetyCode,Sections 25505,25533 and 25534. 1
understand that if the building does not currently have a tenant,that it is my NTWRFSIDENTIALMECH. FTSEP 29 1992
responsibility to notify the occupant of the requirements which most be met
prior t.Issuance of a Certificate of Occupancy. r
I LI I,', ltr
PSz
Owner or authorized agent ., Date ISSUED BY:
TOTAL:
OFFICE COPY