23123 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prue"Identification PERh9T NO.
BzMA� ,a 57 23123
erB arm: One:
6. CITY OF CUPERTINOBUILDING DIVISION q
c°ntra".;.Nana:
Lie.Na: APPLICATION I PERMIT 2' L
Cg.Jr1S� 6co6 / BUILDINGELFLTRICALPLUMBMGMECHAMCAL CATEGORY CONTROLS
Architect/Engineer, Lic.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERh9TISSUANCE •(� ❑ ❑
LICENSED CONTRACTOR'S
pr DECLARATION
I MhSyton OOD)ofam licensedunderBusi nstand of ChionsCocemmmc APPLIANCES-RESIDENTIAL ]OB DESCRIPTION
It...1Sealers 7000)°(Divfect. fthe B°Nnessaod Pm(eeslonsCode,and
license fe In fuB(o and effect. PANELS /r�
License Cl as
Llcp�a_Z&9LA&tA=-&__4JXJ(,tr 1A*q �r
Dale Conlmctar
ARCHITECPS DECLARATION 1201.10DOAMPS
reOz Iundemtand my plans shah be used u pubherrords. OVERIODOAMPS SQ. .FLODR AREA $/SQ.FT.
O pp
Licensed Pmfc.iaml SIGNS ELECTRICAL li L,E D ' N
L OWNER-HOLDER DECLARATION P �' E R
SPECIAL CIliCUIT/MISC
ZF, owing reason.
ton 7031mpt(mms a d Pmfctohs Code:Lawforthe _
Q
following remon.(&elan 71115,Business and Profesalona Code:Anycity or
KF'Iy =ountywhlchrequU aper ttommtmdalter,ImpmvgdemoWh,ornpalr T P'METER OR POLE INST. /An
°'T 7< anystru=lure pdortolts issuance,also requireathe applicant for such permit to `/ GAG
p U file a signed statement that be la licensed pursuant to the provisions of the —DATEPOWER DEVICE'
Contra"or'e License Law(Chapter 9(commencing with Section 7000)of Dlwi-
�� s1on3ofthe Bualnemand Pmfemlora Cede). chat he b exempttherefromand SWIMMING POOL ELECTRIC VALUATION
6 5 the Web for the alleged exemption. Any vlalatlon of&"Ion 7011.5 by any
applleant for a permit subjectsthe applicant to a civil penalty of not more than OUTLETS—SWITCHES-FIXTURES a7
five FILasowneroeshepr. NEW RESIDENTIAL ELECTR SQ.FE STORIES TYPECONSTRUCTION'
�n ❑Lae owner.(the property,or he employem with wagro as thele sole
compensation,wulBotheworkendionst Code:The
Intended orofferedfor
sale(Sec.7614,Buelnna and Profemiom Code:The Contmtors License Law
$$ does notapply to an owner of pmperty who bunds or impravro thereon,and OCC.GROf1Ia RFSM
ATS
whodoessuchworkhlmeelf arlhrough Msownemplayees,provided thatsuch
Improvement a are not intended...ffaredforeale.ILhowever,thebulldingcr TOTAL: S•
improvement bsold wkhlnoneyear ofcompIdioNtheowner-buuderwill have
0W.I:urden of proving that he did not build or Improve for purpose of sale.), Q'ly, PLUMBING PERMIT FEE
u L as owner of the property,am exclusively contracting with licensed FLOOD ZONE APN
contractors to construct the pm)ect(S7066,Business and Pr.fenm ioCade: PERMR155UANCE
m. •QA
n
The Contctn ar's License Law donot apply to an owner of property who ALTER-DRAIN&VENT.WATER(EA) U
Wilds or Improves thereon, and who contracts for such p(o)em with e
cq�((ador(s)licensed pureusnt to the Contractor's License Law. FEE SUMMARY
5I am exempt under Sec B k P C for this reason BACK PLOW PROTECT.DEVICE
OUTS I DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N-
. FE ES
Owner Date RECEIPT M
WORK MAN COMPENSATION DECLARATION FIXTURES PER TRAP 5CITOOLTAX Y N
QI hereby affirm that 1 have a artltirate of consent to self-Insure,ora RECEPT N
nniflmte ofWorkers'Compamation Insurance ora certified copy thereof(Sec. GAS,EA SYSTEM-T INCA OUTLETS � PARKFEE Y
3800,Lb C.) N
a
Policy# RECEIPT#
Com any GAS,EA.SYSTEM-OVER4 MAI B UI L DING DI VISI ON FE BS
�
Certlfled copy is hereby furnished.
OCerifled copy Isfiled with the city Inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF ExfEMPTION FROM WOR KERB' GREASE TRAP PAID
COMPENSATION INSURANCE
(hlssectionneed not becompleted ifthepermit Isf.romhundred dallam SEWER-SANITARY-STORM EA.7(IOPT. Date Receipt#
($1I cerdlesa.) WATER HEATERW/VENT/M TR ENERGY FEE Y N
Icertiess) lnthc,erfomunceoRhewmkf .which this permit bbsued, —
I shall not employ person Ip any manner m t b'et to the WATER SYSTEM/TREATING
Worken'C.mpcn t nLaw fGlifon D tem PAID
O Z Appllcent NEW RESIDENTIAL PLMB. SO.IT. Date RES9I t#
Z p NOTICE TO :IL Aker nu dng b Iflnte o(Exemptbn,you
1" should Wcomn subFd to the W.rken'Com Ion provislom°!rise Labor TOTAL:
to Code,you mustfothwilh comply with such pmvlelom arthla perrraI shell be
It acentsy revoked. UI IN
aCONSTRUCTION LENDING AGENCY SEISMIC FEE
. I herebyaffirm that there Is a comtmeti.n landing agency for the perform- ELECTRIC FEE
Z anceofthework(orwhichthispermitlahaved(Sm.309'7,Civ.C.) TOTAL: .,Op re
V O Lender's Nam. PLUMBING FEE UQ
IL F UnderaAddress QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Iartlfythatl have read this appllcatlonand statethatthe above Information
IL bone".Iagresto comply withal!city and omotyordinancenand slate laws PERMIT ISSUANCE FEES PAID:
>. W relating tobulldingmmtru"Ion,and herebyaulhorlae reprexntativesofthb
I'_ W chytoenterupon the abovem
- entioned inspection for purposes. ALTERORAODTOMECH. Date RCCCI t#
— (We)agree to save,indemnifjdkm harmien the City of Cupertinoagait llablllt dgmenre,cotxawhk msymanywayaccma AIR HANDLING UNIT(TO 10,000CFM) SU$TOTAL•gaWba Id cone nce ing oft permit
AIR HANDLING UNIT(OVER 1g0)0Crnt) CONSTRUCTION TAX
/2
Slgmtureo rector Date .sZ ECFIAUST HODD(W/DIKE) CONSTRUCTION TAX PAID:
HAZARDZARD OUS MA IALS DISCLOSURE
Will the defined
by thcant or e
mrebuilding acipan store or Code,
le 9.1Z andousthe HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as definedodthe Cupertino2(a)? lCade,Chapter9.11,and tis^ -
IleahhandSatetyCade tion 25531(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Vef No
Wlllthe applicant Nm building.ccvpant use ege Bay potent AraAir ca VEMDLA770N FAN(SINGLE RESID) „LSSUA� DATE
which emlthaardou Dair I?amimn/emdefined by the Bay Area Air
Quality Management D'ut tt BOILER-COMP(3II'DR 100,0(p Bill)
yes
(have readtheba rz�i MSmaterials requirements under Chapter 6.95 of
BOILIiR-CAMP(OVLR 100,000 BTU) - r DEC 18 1991
the California Health h S.fety Code,Sections 75505,25533 and 75534.I
and mstan that i f the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ,Fr
4mpomiytoroticecdtheocsto !therequ enanbwhich must be met Cter! heoc=c cvpan CITY VI' CUPEHorlred agent DateI (/
TOTAL: ISSUED BY..
OFFICE COPY