23826 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PFILWT NO.
Building Address: - s /7 0 /�
t(7 -7 LeolA C;f G oG
Fera sect: hone: _ A A A
�
kt I,tJ!/ CITY OF CUPERTINO-BUILDING DIVISION
confraRfor's Name: _ Lie.No: APPLICATION / PERMIT 60 —/Z _9 Z
kz r, I BUILDINGMDC7RICAGPLUMBINGMECFIAMCAL CATEGARY CONTROL#
chitect/Engineer. Lie No:
/ QTY ELECTRICPERMIT FEE BUILDING PERMIT:INFO-
Addrese (� 30X 6 2 &" (� PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECIAR ,TION
I hereby affirm that l am licensed under provisions of Chapter9(commenc- APPLIANCES.RESIDENHAL JOB DESCRITION
Incense is In fon 7000)of DiWfect. ofthe Businessand Professions Code,and my
license is in full(�o(ya/,a_pddlM. I � PANELS
Lire Clan _f=LIC.#
Date--r__�__. s ormidor —UP TO 200 A14!S b
ARCHITECPS :CLAR ION 201-1000 AMPS
aOZp l understand my plans shag be use upublic records. OVER1000AMPS S^Q.Fr.FLOOR AREA # $M.Fr.
V Ucensed Professional - SIGNS ELECTRICAL A` II c� 1/A �-, I� D
r,r'iy ffi
OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC a� I Y �
i., I hereby arm that I ace exempt fromthe Contractor's License Law for the V
J
0 z following mason.(Section 70313,Business and Professions Code;Any city or TEMP.METER OR POLE INST.
mim
t-i9, county which retulmsa pert loconstct,alter,improve,dernalish,or repair
� a anystrutturepriortoitsissuance,alsorequireslheappgant for such permit to
p� O file a signed statement that he b licensed pursuant to the provisions of the TOWER DEVICES 0A E-�'
Q3u'NContractors License Law(Chapter 9(commencing with Section 700))of Divi- SWIMMING POOL ELECTRIC
01 sion3oftheBusinessandProfesslonsCode)orlhathelsexempttherefromand VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHFSFIXTURES
til applicant fora permit subjects the applicant to a civil penalty a not more than
p. five hundred dollars(4500).
I-A' 1,asownerof the property, NEW RESIDENTIAL ELECTR SQ.Fr. STORIES TYPE CONSTRUCTION
z ❑ p ork,a rim my employee with wages u thele tole
ompengi 0K Bann the work and the structure V not intended or offered for
$ O sale(Sec. pply Bu sinessandf property
Code:The Contractor's Liceme Law
does whoclossuch torn owner ofproperty whobuilds norimproves
ovidedreogand OCCGROUP RIS UNITS•
whodoe eats amrkhimse f or Intended
orqugh his own11,howemployees,provided that g car
improvementsarenot intendedproffered(onion.If,bowevee cider ill have TOTAL:
improvement bsold withinoncycaro(completion the owner-bullderwlli have
th,e_p+rdenof proving that he did not build orlmprove for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
L_j L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
rontractom to construct the project(Sec.7074,Business and Professions Code: .0
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EN
Wilda or Improves thereon,and who contracts for such plojecta with a FEE SUMMARY
contractor(s)gcenaed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE OUTSIDE FEES
❑I am exempt under See R&P C for this reason
Owner Data DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
RECEIPT#
WORKMAN COMPENSATION DECLARATION FO(NRFS PER TRAP SCI100LTAX Y_ N_
JI hereby affirm that I have a certificate of consent to self-insure,or a RECEIPT
3R00(ILate Cl Workers Compensatlonlnsurance ora certified copy thereof(5ec. GAS EA.SYSTEM-1 INCAOUTLEIS -DD PARK FFF V N
RECEIPT#
.. PoligY GAS FA.SYSTEM-0VFR4(FA) BUILDING DIVISION FEES
Com any
�Cedified copy is hereby fumished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
I�Certified copy is filed with the city inspection division.
CERTIFIGTE OF UEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM M.200FT. Date RCmipt#
(Thlsseeion need not be completed it the permit is forone hundred dollars
(8100)or legi) WATER HEATER W/VENT/F1-EGTA ENERGYFEE Y_ N_
I certifythat N the performance glthework(or which thin permit is lasted, a
I shall not employ any person in any manner so as to became subject to the WATER SYSTEM/TREATING
Workers Compensation Laws of California. Date - PAID
Oz Applicant NEWRES DEN MLP MB. SQFL Date Remit#
ZO NOTICE TO APPLICANT:If,after ma king this Certificate of Exemption,you
should become subject to the Workers''Compemat lon provisions of the Labor TOTAL:
CCN Cade,you must forthwith comply with such provisions orthla permit shall be BUILDING FEE
W 7 deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL O Iherebyafrlm"Mt there his corstruciion lending agency for the perform- ELECTRIC FEE
D ance of the work for which this permit is Issued(Sec.3097,Cie.C.) TOTAL,
(� O Lender.Nacre PLUMBING FEE ..ro
W F larders Address QTY.I MECHANICAL PERMIT FEE'- MECHANICAL FEE
O W I cedifythatl have read this appliationand statethat lheabove information
lscorrect.l agreetocomplywith all cityand county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} W relatingtobuilding comtrunion,and hereby.whorize repreauntativesoftbk
I. z city to enter upon the abovemenlioned property for inspection purposes. ALTERORADDTOMECH. Date ReCClpt#
(We)agree to give,indemnify an d keep harmless the City of Cu pert Ino
.V against liabilities,rydgnxods,costaand expenses which may In any way.ecom AIR F IANDUNG UNIT(TO 10,ODO CFM) SUBTOTAL:
against acid City in consequence its ip, tingofthlapermit.
AIR lwNvuNc uMT(ovER lo,000clN() CONSTRUCTION TAX
Z--
gnalur of Appgantct
aor Date FXFIAUSTIIOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
' -
Willtheapplies
defined
by the
future building occupant Code, h handle 93Zazrdous IiFATIKG UMi(TO tO0,OD0 BTi)) Date RCCCi t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Pkalth and Safety Code Section 25532(.)7 FITTING UNIT(OVER 100,(100 BTU) TOTAL:
❑Yes n No
Willtheappliant orfuturcbuiidingoaupantuseequlpment ordcvias VENTILATION RAN(SINGLE RFSID) ISSUANCE DATE
which emit harsrdous air contaminants as defined by the Bay Area Air p�
i� Quality Management District? BO[LFR-COMP -I'OR 100,000 BTU) P A ' D
have read the hazardo somateriab requirements under Chapter 6.95 of BOILER-COMP(OVpt 100,000 BTU)
__California Health&Safety Code,$ectiov 25505,25533 and 25534.1 JUN 12 1992
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. IT
SQ. .
responsibility to notify the occupant o(the requirements which murt be mel
prior to Issuance oh Certificate of Occupancy. CITY Lir. (;Ur":ri )IVU
Owner or authorised agent Date TOTAL: ISSUEDBY:
OFFICE COPY