23507 (2) APPLICANT TO FILL IN INFORMP WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification t++ PERWT NO.
Building Address: �' G4F�
_ 23507
hone: APPLICATION77=A A
CITY OF CUPERTINO-BUILDING DIVISION D__Cj_
CamranmaName: V Lia g No: APPLICATION / PERMIT R^\
•1 BURRING-ELECTRICAL-PLUMBING- G LAICAL CATEGORY CONN O
Architect/Engineer. LIC No: _ - .
QTY ELECTRICPERMIT'-n- t FEE. li BUILDING PERPLPLUMB
TINFO
Address, PERMITISSUANCE [:]
LICENSED CONTRACTOR'S DECLARATION y-T
l hereby affirm that i am licensed under provisions of Chapter 9(commenc APPLIANCESRESIDENMAL ]ON DFSCRII'fiON
ingwlth i hi llimm)ddeffeon3o/the BudneaaandProtesslonaCode,and my �0
liconse is in full loroe and dfen. PANELS ; `T,
License Class LiC.N
Dau Cantractar
ARCHITECT'S DECLARATION 201-I000AMPS
Xcc I understand my plans shall be used as public moords OVERI(D)AMPS SQ.FT.FLOD EA s/SQ.FT.
q Z 1j Licensed Professianai SIGNS ELECTRICAL Z�0
OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC
rv'I 1 heuby aRirretiut I am exempt from the Contractor's License Law for the
J_9 following reason.(Section 70715,Business and Pro(esilnne Code;Any city or TEMP.METF7t OR POLE INST.
e=, county,which requires a permit to construct,alter,improve,demolish,or repair
5�rIany structure prior to its ismance,sIm requires thea ppimud fors.&permit to POWER DEVICES
O file a signed statement that he b licensed punuant to the provisions,of the
(OSContractors License lew(Chapter9(commendngwlth Section 7=).f Divi-
alon3oHhe euWea end Profealons Code)arthahebexempt themfrom+nd SWIMMING POOL ELECTRIC VALUATION
the Wats for the alleged exemption. Any violation of Section 7m I-I by any
30f� applicant fora permit subjects theappilcanttoativll penelty ofnn morethan Im,ETSSMTCHESbFIXI.URE5
dred d altars($Sm. NEW REMFIMAL ELECTR SQFT.
s owner of the property,or my employees with wages u their sale STORIES TYPE CONSFRIKTION'
o nation,will d°the work and the structure is not intended or offeredfor
,iCO (Sec 7064,Business andfpmpcny Cade Theorimpn nthE m law
j $ donrwt apply toenownerofpropertywhobu,M orimprovethereon,and OCC.GROUP RES.UNTFS
wh°doementsa not Inttelfedorsugh hisownemp,henxeprovidedilding or
imprevernordo mnotintendeyearofcomproffered rnk.lLhower-brudthe erwill have T LIQ
' provement aeold withinoneyvarofcompletion,the owner-bu0derw111 have ,
thAvMenofpmvingthat he did notbuidorimprovet°rpurpoxofsale.). QTY, P' +"PLUMBINGPERMIT"-, :� •FEE: FLOODZDNE APN
LJ L as owner of the property,am exclusively contracting with licensed
contractors to mmtrvn the pmject(SeC 7064,Business and Profeaims Code: PERMIT ISSUANCE
The Contractors License Law don not apply to an owner of property who ALlI]t-DRAIN&VEtxT-WATER MAI
or Improves thmnnt
o ,and who conm for such p,je to with a
i,Ilt(actor(s)Bcensnd pursuant to the Contractor's License Law. BAIX FLAW PROTECT.DEVICE ) - FEE.SUMMARY'�-
I am exempt under Sec B k P C for this reason
a'. Owner Date DRAINS FLOOR ROOF,AREA,MND. SANrTARY Y_ N_
WORKMAN COMPENSATION DECLARATION RECEo'r N
❑1 hereby affirm that I have a wriiRcate of consent to seltdnsure,or a FIXTURRS PER TRAP SCHOOL TAX Y_ N_
certificate of Workers Camperwtlonlvuranceori certBied copy thereof(Sec. RECEIPT N
3800,Lab C.) GAS EA.SYSrFA{-1 BVG40IJTI.ETS PARK FEE Y N
Policy N RECEIPT N
Com ray GASEA.SYSIEMAVER4(FA) BUILDING DI VIB4FEESCertified copy la hercbyth theced. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE Certified copy V filed with the city WpMlon division.CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID _COMPENSATION INSURANCE(Thlssection need not Wcompleted Bthepermit bforone hundred dollars SEWER-SANTfARY-'STORM FA.20CFr. Date WATER HEATER W/VE\7/ELECTA ENERGYFEE YI certify that in the perfomunmofine work forwhlch thus permit to issued. ^I shall not employ any person in any manner so as to become subject t°the7YA.p��,�,�/,ygFA,nNG LWorkersCompensationlawsofCalifomla. Date PAID
ZApplicant Dale
_ O NOTlCETOAPPLICAM:e,aheues'C.enper Cthr.Preis Exemption,you '�T'`r RESIDENTIAL PCMB._SQFr.
Code,shoulyou
use=at subjecttothe Workers Compemasio provisions,permit
Labbe TOTAL:
W
Code, re elmd.forthwith comply with such pmvisioa orth4 pemdt shill W _
� > deemea retakes. BUIL12ING FEE
C CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z [hereby a(firmthattWreuacoretroctlon lending agency for thepeAomf ELECTRIC FEE
ance of the work for which this permit is issued(Sec.309'/,Civ.C.) TOTAL:
O Landera Name . PLUMBING FEE
I- lenders Addmss Qn. MECF'IANICAti PEBMFC ^ .:-FEE
W lcedl(ythatl have read lhiaappLcationand statethattheabove lom
foration MECHANICAL FEE
0. is correct.l agree to comply with allcity and county ordinances and pate laws PFRMRL4TIANCE ^ FEES PAID:
W relatingtobullding comwction,and hereby authorise es
repmaormtivofthh
Z cityto courupon the abovennontloned property for Wpectlon purposes, ALTFRORADDTOMFCH.
(We)agree to save,t emNfy an d keep harnrdev the City of CupertinoI Date Receipt#
agai tliabilitles,jud rats,castsend nsea whichmayinanywayacaue AIRHANDLINGUNTr(r010,000CFM) SUBTOTAL:
zgai taaid Ci onses(uence o! gnntingof t7Z2/92—
detractor
l permit.
2 Z AIR HANDING UNTr(OVER Io,"CFM) CONSTRUCTION TAX
'ig m Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building°cmpantstou or handle hazardous HEATING UNIT(TO 100,1100 BTT I)
material as defined by the Cupertino Municipal Code,Chapter9.12and the Date RCCCI t#
I I❑ YSnd Safety Code,Section 2ii37 (a)7 HEATING UNIT(OVER 100,0W RM TOWill the applicant or❑future building occupant use equipment or devices VEN'TIAT10NFAN(SINCLE RESID) ISSUANCE DATE
which unit hazardous air mntand uirda m defined by the Bay Area Au
Quality Management District? BOILER-COMP OHP OR 100,0(0 BTU)
4Yes d the i2 No r
havemaHealth&Safetmoe,Sc larircrrcntsunder 5533anhapter6.9iof eOLER-MMP(OVER IW,000BTU) F
the California Health h Safety Coda Seniors SS0.i,21533 and 25536. 1
understand that lithe building does not currently have a tenant,that it is my NEW RESIELN-IAL MECH. SQ.ET. ,�ryry
r riot to Issuance
cda Ckhe ocmpant of tparcy.rements which must be rrct (/� J/all
priortoissuanceola Certifiate oflhcopanry.
Owner orawhortsed agent Date
' l ISSUED BY: t /I
OFFICE COPY