23113 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALLPOINT'PEN ONLY
Building Project Identification PERMIT NO.
Budd ing Address: (,131 13
wnera ante: one. - - APPELcATA
CITY OF CUPERTINO-BUILDING DIVISION
Cnno-raad/ofaName: lLkG.N.: APPLICATION / PERMIT .
6
S �sJ?/7J BUILDINGS.ECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL p
Architect/Engineer. 17 Lie.No:
Qn ELECTRIC PERMIT FEE - BUILDING,PERMIT INFO
Add.. R' PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOS DECLARATION
I hereby
affirm that suf CLapter9(mmc
APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwlthxctior7000).f ivxi.3
ofthe Bustnessand PmfessionaCode,andmy
lien.is 1.fuB rce and effeet.
ate-' n PANELS ^ /
License lass _ Lic.N -1J.777
Date ' Contractor_= _� UPTO 2DOAMPS V•L f/`.li(
ARCHITECTS DECLARATION
ggqaZz IundcmtandmyplamahaBWusedupublicreronrs OVERIO(IOAMPS - F-7p"''IJi Q$FA I $/ .Ff.
Licensed I'mfesslaml SIGNS ELECTRICAL �! �I E D
¢ OWNER-BUILDER DECLARATION C
III Xp hereby Pt SPECIAL CIRCNT/MISC 1f 1� n ® ' f C
Iwingasearmthatlam exempt fronts a Contractures Code:
for he w' 1 V
OZF.� following reason.(Seation 7QI15,Business and Professions Code:Any city or TEMP.METER OR POLE INST.
cou
�pp ntywhkhrequiresaper twmmtmdalter,improve,demolbh,orrepair
S.:u anystm=mpriortoltslwamce,aborequlmstheapplleantforsuchper tto POWER DEVICES DA E
CCF file a signed statement that he is licensed pursuant to the prowdom of the
�3u,N Contractor's License Law(Chapter 9(ecmmening with Section 7000)of DIW- VALUATION
SWIMMING POOL ELECTRIC
sion3 ofthe Buslnessand ProfrsslomCode)orthathebexempttherefromand
ILL"'jjjglld the basis for the alleged exemption. Any violation of Section 7031.5 by any 6UIlE.ISSWLfC1[ESF7%.LURES
appBeant for a peanut subjecta the applicant to a civil penalty of next rture than
m o five hundred dollars(95(1(7).
I,as owner of the NEW RESIDENTIAL ELECTR SQ.FC. STORIES TYPE CONSTRUCTION
Z ❑ property, employees
cum(Sce.7 on,wW Bothe work and the structure Jared Wended or offered for
5 O sale(Sec.7046,Buid ess and Professions Code:The Cormactors License Law
does not apply to an owner of property who Wilds or improves thereon,and OCC.GROUT' AFS.UNITS
who does such work himself or through his own employees,provided that such
improvements am not intended oro/fered for sale.If,however thebuilding er TOTAL:
Improvement issold withinoneyearofcomplelb theowner-WiMerwill have
tflt�+ enof proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE. FLOOD ZONE APN
L�.L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7014,Business and Professlora Code:
The Contractor's Licertx Law does net apply to an owner of property who
Wilds or Improves thereon, and who contracts for such ptojecb with a ALTER-DRAIN&VENT-WATER(EA)
m,,11LLt.(dor(s)Imeaed pursuant to the Contractoh License Law. FEE SUMMARY '
IJ I am exempt under Sec. B&P C for this reason BACK FLAW PROTECT.DEVICE
DRAINS FLOOR A,ROOF,AREGOND. SANITARY Y_ N
•
Owner Date m RFCQI'I'
X
WORK MAN COMPENSATION DECLARATION F.IX.N��TRAP SCHOOL TAX Y N
❑I hereby.(flim that I have a certlfieate of consent m ul(-inw
or RECER'f N
certificate ofW.,keri Compensation]nsurance or a certlfled copy thereof(Sec. GAS EA:SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,Lab J RECEIPT
PolicyN vc Y Dba-s - / GAS F.A.
A.SYSM-OVFR4(EA)
BUILDING DI VISION FEES
Certified copy Is hereby
CenJied copy u filed with tcity tthe he W peeHon division..d. GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
fJI
CERTIFICATE OF EREM PfION FROM WORKERS' GREASE'IRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Recei t#
(Thissection need na M completed Bthe permit Is for one hundred dollars
($1000 or less.) WATER HEAITA W/VEM/FI.ECTR S'J ENERGY FEE Y_ N
I certifythat In the performance of the work forwhlch this permit Is iswed, a
I shall not employ any person In any manner m ns to become subyd to the WATERSYSTEM/TREATING >
Workers'Compensation Lawa of Callfomia.Date LAID
O Z Applicant NEW RFSIDENT[AL PLMB. SQ.PT, Date Remi t#
Z O NOTICETO APPLICANT:If,after making thisCertificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
W Code,you most forthwith comply wlthsuch proveomorthA permit shall be
W > deemed revoked. - BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Ihombyeffirm that them 6 a construction lending agency for the perform- ELECTRIC FEE
TOTAL r
7 Z ance o/the work for which this permit E lswest(Sec.3097,Civ.C.) ��eJ f2
00 Lenders N.me PLUMBING FEE 2J
LL F Lender'.Address QTY.I MECHANICAL PERMIT FEE• MECHANICAL FEE
O W Icertilythat l havereadthisapplloM t
ttonaatethatthe above Information
u correct.l agree to comply with all cityand county ordination and state laws PERMRLSSIIANCE FEE$_ PAID: 1
>_ N relating to building conswction,and hereby authorlurepreaentaeveaofthb - - j�,3/��
city to enter upon the above-mentioned property for trapeetion purposes. ALTPRORADDTOMECH.
Z (We)agree to save,Indenudy an d keep harmless the City of Cupertino - Date Receipt#
V against liabilities,judgments,costsand expenses which may in anywayarstue AIRHANDLiNGUMT(rOI0,000CFM) SUBTOTAL:
against said City in conscyuence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date F3HAUSTHOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appBcant or future Wilding occupant store or handle harardoes HEATINGUNIT(TO100,OWBFU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I ealth and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yea
Willfleappllont Xm building occupant use equipment or declines VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit harardom air contaminantsas defined bythe Bay Arca Air a q
Quality Management ct? BOILER-COMP OHP OR 100,0W BTU) r AI 'D
4Yes `%bbU No
hyesmail the haz#dbusmaterials requImmentsunder Chapter 6.95of BOILER-COMP(OVER IW,000BTU)
the California Health&Safety Code,Sections 25505,25533 and 2!iSM.I DEC 30 1991
understand that if the building does nm currently have a tenant,that it is my NEW RESIDENTIAL M1KTL SQ.Fr
responsibility to notify the occupant of the requirements which must be net "
p ito issuance o(aCertif to Ompan —_ CIIr ut,* '.Cf111NQ
01vocr or authorized agent Date 155UEDBY: %ATOTAL:
OFFICE COPY