23493 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - - PEEMITNO.
Building Address:
10)136 LeRkArdn/ gjkUU 23493
rs ams: , -
A A
� •�5 L -3�(4 CITY OF CUPERTINO-BUILDING DIVISION � q Z
-� Contratorallorne: Lie.No: APPLICATION / PERMIT L
BUILDING-E.ECTMCALPLUMBINGIIA
MECNTCAL CATEGORY CONTROL N
Arohltect/Engin .e Lk.No:
QTY' ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address: PFRMEEISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l sin licensed under provisions of Chapter 9(comovem, APPOANCESRESIOEMTAL ]OB DESCRE9lON
Ingwith5ection 7000)o(Divislon3ofthe Businmand PrefmionsCode,and my -
license lsinfuBforce and effect. - - PANEIS
License C6n mnr
Date CContractor '1./•
ARCHITECTSDECLARATION N'
0A !'$
0OZ (understand my plans shag be used upubbcremnis OVER OVERI1000 AMPS SQ.Pr.FLOOR AREA 5/SQ.FT.
NUB Licensed Profesrianal SIGNS ELECTRICAL
G 6 ere. OWNER-BUILDER DECLARATION /
7 p., mving yasormlhatlamexempt fromthe Contractor's License law fort he
SPECIAL CIRCUIT/ML9C
pp following reason.(Se tion 7031 S,Business and Professions Code;Any dry or
O 2.F. TIME.METER OR POLE(NST.
rountywhich requlaesapemNtto mmtrot,ilter,lmprove,demolish,orrepilr
Gany structure prlorto its lswrance,aiso mquiresthe applicant lorsuch permit to POWER DEVICES
file a signed statement that he et licensed pursuant to the provisions of the
3 u Contractors License law(Chapter 9(commencing with Section 7!100)of Divi- SWIMMING FOOL ELECTRIC
F�O� sion3ollhe Businm and ProfmiamCode)orthat he is exempt therefromand VALUATION
the hisis for the alleged exemption. Any violation of Section 7011.5 by any OUILEISSWITCHFSHXTURES
«oo
applicant for a permit subjects the applicant to a civil penalty of not more than
O R five hu d dollars($500).
4fas owner of the property,or my employees with wages as their sale NRW AES[DENIIAL ELECIA SQ STORIES TYPE CONSTRUCTION
/- compensation,wlliciothe work andthestructure B,not intended or offered for
❑ sale(Sec.7044 Business and Pmfeasiom Code:The Contractors License Taw
does not apply to an owner of property who Wilds or improves thereon,and - OCC.GROUP RFS.UNITS
who doessuch work himself orthrough his own employees,provided that such
improvements arc not intended oroffered for sale.If,however,the build Ing or TOTAL:
improvement Is sold within onyearofcompitlon,the owner-budderwlll have
the burden of proving that he did not build or improve for purpose ofsale3. QTY. PLUMBING PERMIT .,FEE
LUJ LANE APN
L as mucor tr the property, Se exclusively Business
and Ing with licensed PERMIT ISSUANCE
TheconContract is Lim thew doe(notc.app!Businm and of prilon Code:The
Contractor's Llre law does net apply to an owner of property who ALTER DRAIN&VENT WATER(EM
Wilda ar lmpr
071 7..
and pt mnct.de for such plojecb with a FEE SUMMARY
c,,Il➢.t{.fator(e) 'e Cyt-punuanl fie onlratare License law. BACK FLOW PROTECT.DEVICE
L�I am x t t' der B &P C (or tM1p reasonOUTSI DE FEES
,(/��°(-,�L____ DRAINS FLOOR ROOF,ARCA,GOND. SANITARY Y_ N_
. Own Dxe RECEIT N
WORKMAN COMPENSATION DECIARATI FD(TURES PER TRM SCHOOLTAX Y_ N_
ereby affirm that I have a certificate of consent to self-Inure,ora RpApTIF s
certificate of Workera'Compeneatlon Insurance or a certified copy thereof(See. GAS EA.SYSTEM-1 IVCAOUTLETS PARKFEE Y N
3800,lab C3 RECEIPT a
Policy# GAS EA.SYSfEI- VERd(FA)
Cam any - BUILDING DIVISION FEES
[]Certified copy is hereby filed
the city
d. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
Certified copy is filed with the city inspetlon division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.2(XIFI. Date RL'ceip[p
(Thissetlon need not be completed lithe permit Is for one hundred dollars
(8100)arlm.) wATEcfiFATFR w/vENr/F1.ECIR' ENERGY FEE' Y N
I cefflythat in the performance olthework forwhlch this pe.It is issued,
I shall net employ any person In any manner so m to become subject to the WATER SYSTEM/TREATING
Workers Compensation Laws of California.Date PAID
OZ Applicant NEW RESIDENTIAL PCMB. SQ.FI'. Date Recet#
i
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Warless'Compenation provision of the Labor TOTAL:
CCLn> Cade,you must forthwith comply with such provisions orthbpermit shall be BUILDING EE —0I1
WG deemed revoked. _
dCONSTRUCTION LENDING AGENCY SEISMIC FEE
Ihembyaffirtnthatthere isammtrutlon lendingagenry forthe perform TOTAL: ELECTRIC FEE(Sec.anceofthe work!orwhich this permit is Luued(Sec.3097,CIv.C3
00 Lender's Name PLUMBING FEE
IL r LendersAddrera QTY. MECHANICAL PERMIT ITE MECHANICAL FEE
OW l certifythat l have readthisapp5cation and gate thatthe abovelnfomattmt
C beorretl.I agree to comply with acity and county ordinances and gate laws PERMIT ISSUANCE FEES PAID:
N relxtingtobullding construction,and herebyauthimserepresentativesofthis
citOt -eabov e-men caned property for Wpection purposes. ALTERORADDTOMECH.ZDate Recci t#
dkeep harmim the City o/CupertinoPgment /Gac de nxa whichmayInanywayaccrue AIR HANDLING UMTffO tO,WOCFM) SUBTOTAL'
n of s"pemni.
/— AIR HANDLING UNIT(OVER 10,O CFM) CONSTRUCTION TAX
ature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle harardous HEATING UNIT(TO 100,000 BTU) Date Receipt I If
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Healthand Safty Code Se n755324)7 IiEATINGUMT(OVER100,"BW TOTAL:
❑Yea o
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESiD) ISSUANCE DATE
which emit harardous contaminants as defined by the Bay Area Air
Quality Management Dutri BOILER-COMP OFI'AA 100,000 BTU) PAID
4Yes o
haveread thehoca ousmaterialsrequirementsunderChapter6.95of BOILER-COMP(OVER 100,000 BTU)
the California health&SafetyCode,Sections 25505,25533 and 755M. I APR
La
understand that lithe building does not currently have a tenant,that it u my N'EWMT
RESIDEALMECiiAPR: SQ.FI ll - 1992
responsibility to notify the occupant of the requirements which most be met -
priortoissuancecis Certificate°f Occuparry. - -
C.PfYIh LrL cnlirvV
Owner or authorlmd agent Date ISSUED BY_1 X
TOTAL:
OFFICE COPY