23822 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ed Identification PERMIT NO.
Build 362 Ltolq J- 23822
nets ams: one:
A A A
Ike , S - 9L3i CITYOFCUPERTINO-BUILDINGDIVISION
Centra nrsNam: Llc.Nn: APPLICATION / PERMIT &'- �2—
V at I BUILDING-ELECTRICAL-PLUMBING-MFCH LAICAL CATEGORY - CONTROL p
' Architect/Englure Lk.No:
QTYELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: .0 (;0 2 S '4r PERMITISSUANCE 1:1 1:11� ❑
LICENSED CONTRACTOR'S DECLARATION
I herebyafirm that l am licensed under provisions of Chapter 9(commenc APPLIANCES RESIDENTIAL JOB DESCRIPTION
ingwith Section 7000)of Divislon3otthe BusinessandProfesifi esCode,and my
license Is In full force and effect. / PANELS
License Cha L�2( Lk.p '
Date 6�11 n?Contractor �i —UP TO 200AM5
ARCHITECT DECIA ATION 201-IOW AMPS
7 1 understand my plata shall be us d as public records. OVER IODO AMPS SQ.FTrFIIbOR AREA E/SQ.FT.
o O �^— p ^
�G L U Licensed Pmfesslarul SIGNS ELECTRICAL 1'—^ C .1 `.\ ® ��
<ce - ffirm
OWNER-BUILDER DECLARATION
SPECIAL CIRCUIT/MISC
Thereby a ]tiexempt xempHromthe Contractor's License Law for the
7 0 '� following reason.(Section 70115,Business and Professions Code:Any cityor
Q7t"'t� countywhich requlresa peomittocmwtruct,alter,Improve,demnllsh,orrepair ThMP.ME1T920R1'OLE INS?. ��/ ���
54a.a anystructure priorlo its issuance,aborequires theappBcant foisuch permit to
,PYLA F file a signed statement that he is licensed pursuant to the provisions of the [OWER DEVICES
Rpp?S5 0 m Contractor's License Law(Chapter 9(com nsucin with Section 700) of Divi-
f�0 sion3ofthe Businessand Profeslons Code)orthatt heis exempt therefromand SWIMMING POOL ELECTRIC VALUATION
M1 d the basis for the alleged exemption. Any violation of Section 70315 by any
<5 OUTLETSSWITCHESFIXTURFS
ri' oo applicant for permit applicant dull penalty of net more than
F- o u. five hundred dolhrs(5500). NEW RESIDENTIAL ELECTR Fr.
�n �[ as owner o(the ro SQ STORIES TYPE CONSTRUCTION
, p petty,or my employees with wage as lhe4 sok
C74 compensation,Business PGandthestructure I,not intended or offered for
D ale(Sec.7646,Business and Pmfealore Code:The Contractors License Law _
NW-$$ does nm apply to an owner of property who Wilds or improves thereon.and OCC.GROUT' RES.UNITS
who does such work himself orthroigh his own employees,provided that such
improvements am not Intended oroffered for sale.IL,howevepthebuildingor TOTAL: -
impmvementusoldwilhineneyearofcompleti theowner-bWlderwillhave
the burden of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD IpNE ApN
F-1 L as owner of the property,am exclusively contracting with licensed pp H ISSUANCE A
contractors mto construct the project(Sec.7014,Buslnessand Profens ssioCode: •DRI
The Contractor's License law does net apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or tpmves thereon, and who contracts for such pippets -
with a - FEE SUMMARY
ontt(actor(a)licensed pursuant to the Cantractor'e License Law. BACK FLOW PROTECT.DEVICE
IJ I am exempt under Sec B&P C for this reasonOUTSIDE FEES
Owner —Date DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N_
RECEIPT Y
•' WORKMAN COMPENSATION affirmDECLARATION . SCHOOLTAX Y_'N_
❑I hereby that 1 have a cenl0ate of consent to x61n
1sure,ora RECEIPT A
certificate of Workers Compensationlnsurance oracentifted ropy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS `� PARKFEE Y N
3800,Lab C.) 3-O O RECEIPT'4
Policy p GAS'EA.SYSTEM-OVER 4(EA)
Com any BUILDING DIVISION FEES
Certified copy k hereby famished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
MCanified copy is filed with the city Inspection division.
CERTIFICATE OF EXWPTION FROM WORKERS' GRFASETRAP PAID
COMPENSATION INSURANCE $EWER SANITARY STOILM FA 2WFT Dale RCCeI tN
(Thisaection need not be completed if the permit is for ore hundred dollars
($1 mAifyth WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
I cent em t oyin any pehe f n in any h nnerwork o,wMch this pembjeit c to theed, e
I shag not employ any person in any manner m u to become subjm to the WATER SYSTA(/TREATING
'Workers Compensation laws o(Californla.Date PAID
O Z Applicant NEW RESIDFNIIAL[,LMB. SQFT. Dale RCCCI f(t
Z O NOTICETOAPPLICANT:ILaftermaking Chia Ccniftoteof Excmptlon,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
TCode,you most forthwith comply with such provisions orthis permit shall be BUILDING FEE
LU > deemed revokes.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d . Ihereby affirm that there is a cerstmctlon lending agency for the perform- TOTAL: P� ELECTRICFEE
Zanre of the work for which this permit h inued(Se,3097,Civ.C.) �U
U O lenders Name PLUMBING FEE
F' Lender's Address - QTY. MECHANICAL PERMIT FEE
O W MECHANICAL FEE
Icenitythatl have readthuapplimtionaMmatethattheabovelnLomutlon
1 iscomon.l agmeto comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID.
>. relating to building construction,and lunabyauthorlae representativesofthis '
(_ (n city to enter upon the abavcmentbned property for Inspection purposes. - ALTERORADDTOMFCH.
Z (We)agree to save,Indemnify and keep harmless the City of Cupenmo - Date- Receipt#
O pgalnstlhbllitks,jidgmenb,cosh and expenses whkh may In anywayaccrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against sold City In consequence of the&,anti gof this permit.
�� N� 2 AIR HANDLING UNIT(OVER I0000CFM) CONSTRUCTION TAX
�'-12 CONSTRUCTION TAX PAID:
Wrco ppBa HAZARDOUS
Date IXHAl15T HOOD
MAZA BDOUS MATERIALS DISCLOSURE
Will the applicant orthe
Cupertino
Municipal
ode, hapten le 9AZ and
I{I%sTINC UM7(TO 1W,W0 BTU) Date ReCef tN
I kali Naas defined by the Cupertino Munidpal Code,Chapter 9.12,and the
Ekalih and Safety cod,Section 75532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes b No
Will the applicant orfutum building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havrdous air contaminants as defined by the Bay Area Air �L
Quality Management �'k District? BOILER-COMP OHP OR I00,0M BTU) r A D
Yes ❑
No
`(have read the bazallous materials requirements under Chapter6.95 of BOILER-COMP(OVER100,000 BN)
the Ca lifornla Health&Safety Code,Sections 25505,25533 and 255M.1 yy RLSIDENTIAL MECH. SQ.FT JUN 12 1992
understand that if the building does not mrrently have a tenant,that it is my
'responsibility to notify the occupant of the requirements which must be met
prior to Issas are of a Ccnl flats of Occu pa nry. '
CI I Y Ur laUrcn I).vu
Ownet w e ithorlud agent Date ISSUED BY.
TOTAL:
OFFICE COPY