23740 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES _ USE BALL POINT PEN ONLY
Building Project Identification 'PEIihIT NO.
Bvildtn Address, &r 23740
07� ��
erre: hone: A A A -
(,� CITY OF CUPERTINO-BUILDINC DIVISION S Z 8-`(2
C dmt,N=^� G N. APPLICATION / PERMIT `
BUILDINGELECTRICAI PLUMBING-MECIIAMCAL CATF-CRY CONTROL#
Architect/Engineer. PV Lk.No:
1,k QTY - ELECTRIC PERMIT FEE
BUILDING PERMIT INFO'
-Addmia363#�.•�.Q'r c-sly.f r&n,� PERMITISSUANCE � ❑
LICENSED CONTRACTOR'S DECLARATION
Thereby affirm that l am licensed under provisions of Chapter 9(commenc- APPLIANCES-RESIDENTIAL JOB DLSCRIPRON
ingwlth Sedion7000)of DiWsion3 oflhe Businessand ProfesdonsCode,and my
It .Is in full force and died. PANELS
License Chea Lic.41
a[e Contractor IM IQ 2NAMPS
ARCHITECTS DECLARATION 701-1000 AMPS
SQ.Fr.FLOOR AREA $/SQ.FT.
��Z IuFlye dmy ply®shali�e used as public records. OVER 1000 ANTI'S I,� fy���
c+U,U— Limn`sed Professional(" SIGNS ELECTRICAL II R ® E V
f 6 w OWNEReBUILDER DECLARATION / �,;,.. , sok
lin y SPECIALCIIiC!I- MISC ly
Ihereb affirm thatlamexe5, fmmthe Contractors Code:Law fort he G l
following reason.(Section 7031.5;Business and Professions Code:Any city or y^
county which requires a permit tomwtruct,alter,Improve,demolish,orrepair TEMP.METER OR POLE INSC. /
�f �¢ anystm=mpriortoibbmance,ah mqulrestheapplinntforsuchpermitto POWER DEVICES I DATE /
U file a signed statement that he h Bmnsed pursuant to the paovieforo of the 1
�3w Contractors License Law(Chapter9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC—•
O sion3ofthe Businessand ProfessionsCode)orthat heisexem therefromand VALUATION
the basis for the alleged exemption. Any violation of Section 70315 by any OUTLETS-SWITCHES-FIXTURES
applicant for a permit subjects,the applicant to a civil penalty of not mare than
live hundred dollars(SM. SQ, STORIES TYPE CONSTRUCTION
I as owner o!the property,or employees with wa es as their sole NEW RESIDENTIAL ELECTR FT.
^[N ❑• P Perry, myB
k,7.� compensation,Business andk,andsnoCdvrchn ontractor oroans,d for
Law
❑ sale(Sec.apply
to Business and Professions Code:The or impoctols Limine Law
$ does notapply torn owner ofthroug his own
WildeorImprovesthereon,and OCC.GROUP RES.UNITS
who dors such work himself edoroughhisowne.If,ho eprovidedthatsuch
improvements am not intended orolfered forsale.fL however,thebulldingor TOTAL:
improvement issold within mncycarofcompldimntheowner-bulidcrwlll have
th�rden of proving that he did not build or bmprove for purpose of sale.). QTY. PLUMBING PERMIT .FEE
L as owner of the property,am exclusively=trading with licensed FLOOD ZAMi APN
contractors to construct the project(Sm 70K Business and Professions Code: PFRMITLSSUAN'CE r
The Contractors License law does not apply to an owner of property who ALTER-DRAIN VENT-WATER(EA)bauds or Improves thereon,and who contracts for such pi ejects with a FEE SUMMARY
ro,,BBVVador(s)licensed pursuant to the CmUnctori License Law. BACK FLOW PROTECT.DEVICE
L.I1 am exempt under Sec. B &P C for this reason
OUTSIDE FEES
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
RECEIPT If
WORKMAN COMPENSATION DECLARATION FIXTURF_S PER TRAP SCfiOOL TAX Y_ N_
❑I hereby affirm that 1 have o l rtme of consent to self-insure,ora RECE'r#
ceniflLab of Workers'Compensationlmurance ora certified copy Chemo((Sec. GAS EA.SYSTEM-I INCA OUTLETS PARK FEE Y N
3800,lab C.) —
On a RECEIPT N
Com any GAS EA.SYST[hi-OVERd(FA) BUILDING DIVISION FEES
-MCentned copy is hereby filedwtumbhed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
f Cedifid copy b filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SbIYER SANITARY STORM EA.100E 1'. - Date Reeei [#
(this section need not Is,completed if the permit b for one hundred dollars
($100).,less) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I ormlythat in the performance of the work forwhlch Ws permit is iswd,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers Compensatimnlawsof Callfomb.Date PAID
0 Z. Applicant NEW RESIDENTIAL PCMB. SQ.FT. Date RCCCI [#
Z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers ns
Compeation pmvhattoof the Labor TOTAL:
N- Code,you imus:forthwith comply with such provisions or this permit shall he BUILDING FEE
LU j deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d I hereby affirm that hem is a commotion lending agency forthe perform ELECTRIC FEE
7 Z ame of the work for which this permit is Issued(Sec.3097,Civ.C.) as
00 Lender'.Name — PLUMBING FEE
LL lender's Add reae QTY. MECHANICAL PERMIT. FEE MECHANICAL FEE
OW 1cerhfylhat l have rcadthb application and statethatthe above information
1 ucormet.7agreetocomplywithalldtyandmuntyoNin=nu dstatelaws PERMIT ISSUANCE FEES PAID:
>. N relating to building constmetion,and herebyaulhomierepresentativesofthb
F. city to enter upon the abInspection property for InspectionERH.
lon purposes. ALTORADDTOMEC
Z DB[C RCCCI [#
_ (We)agree to save,Indemnify an d keep harmless,the City of Cu petition P
against liabilities,ydgments,costs a cad expenses which may In any way same AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
g tmld Cit I consequenceof lee grantingdthbpernit.
d AIR HANDLING UNIT(OVER 10,1X10 CFM) CONSTRUCTION TAX
�� CONSTRUCTION TAX PAID:
Sere ppiHAZA DO Date EXHAUST HOOD(W/DIK:p
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant d by thfuture Cupertino
gompantstore ode,Ch pierhanle olZa rdous HEATING UNIT(TO t00,lXM)BTII) Date Receipt#
material as defined by the Cupertino Municipal Code,Chapter 9.1;and the
HF-I Yead Sally Coda Section 2SS32(a)7 FIFATING UNIT(OVER 100,000 BTU) - TOT
❑ll n No
which
end,applicant orfumrcbuilding a,defined
ndby Ile Bay Area devices VENTILATION FAN(SINGLE RESID) ISSUANCElD,ATE
which¢ larand air District? vats as defined by the Bay Area Am r A I V .
Quality Management District? MOILER-COMP(31-1'OR IIXI,O(MI BTU)
Yn
[j No
4havcread the hazarommaterials requimmentsunder Chapter 6.95of BOMER-COM.P(OVER 100,000BTU) MAY 27 1992
the Glifornla Iiealth&Safety Code,Sections 75505,25533 and 255M.]
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. .FT,
responsibility to notify the occupant of the requirements which must be and 011 Ur QUYLn I I"
prior to issuance of a Certificate of Occupancy. -
Owner or authoneed agent -Date FT ISSUED BY: VV
TOTAL:
OFFICE COPY