24020 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT Ng O O
B.Bdmg Address: Z
D
wmra arae: one: A
�ao2-25 CITY OF CUPERTINO-BUILDING DIVISION � _ n
on',!k
� LIc.No: APPLICATION / PERMIT b
r C� Qt" 5099168 BULDINGELECTRICAPUMBINGMECHAMCAL CATEGORY CONTROL
rchltect/Fsgineen Llc.No:
7 QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: B,Q ad.. �- PERMITISSUANCE ��� ❑ ❑ ❑
LICENSED CON ACTOR'S ECLARATION
IhthScdk Rrrnthatlam Bcmudunderprovtalon,of Cha r9de,and c- APPLIANCESRESIDENTTAL JOB DFSCRUMON
ingwlth5ectlon 7000)o(Divimon3.fthe Bumnessand Isrolesmon,Code,and my s
licenseisin full fo and Lt.
`` PANELS
License Cl Lie N 670 6 t
Date B' Contnaor
—UP TO 2QO ANTS
A12011070 AMPS
(�teO Zp I understand my plans a public records. OVER 1070 AMPS f�SQ.FT.FLOOR G I $/SQ.Fr.
,Z o Li...d Professional SIGNSELECTRICAL f',
< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC 9 V Y
to.., Iherebya(firm that OWNEexempt ER the LARATIContractors Lkense law for theER 6O 2 following reason.(5e Uon 7031.5,Business and Pmfesdons Code:Any city or ffq ��
F,. i-'u9 countywhi6mrequlresapertmttomrwmd,alter,Improvgdemolbh,orrepair TIME.MEFEt OR POLE INST. ,S
'� anystmmm prior to its a asuance,alsorequires theapplicam forsuch permtto [U(
- file a signed statement that he 6licensed pursuant to the provisions of the POWER DEVICES
Contractors License Law(Chapter 9(commencing with Section 7000)of Divi- SNC IDOL ELECTRIC h,F90..1 awn3 of the Business and Profemlom Code)or that he 6 exempt therefrom and SW1hVALUATION
yF�y1 the basis for the alleged exemption. Any violation of Section 7m1.5 by any
pti applicant for a permit subjects the applicant to a rnll penalty of not morcthan .110UTLETSSWITCHE-FIXTURES �N141,49_ . -
a o five hundred dollars(5500). NEW RESIDENTIAL ELECTR
I,a.owner of the TRFL STORIES 7YPG CONSTRUCTION
,Z ❑ property,or my employees with wage a their sole
C compensation,will cloths work,and thestrvcture is not Intended or offeree for
$�o sale(Sec.AiE Business and Pmfeavions Code:TM C.Im.d.e.License Law
�S r$ does not apply to an owner of property who Wilds or Improves thereon,and .
who does,uch work himself orthrough his own employees,provided that such OCC.GROUP RESUNITS
Improvements arc not intended°roRered forsale.If however thebuliding or TOT
AYImprovement Issold within oneyearo(compietiomtheowner-bullderwill have
th ,den of proving that M didnot build.,improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FIADDZONE APN
I,as owner of the property,am exclusively contracting with licensed PERMIT LSEUANCE
contractors to construct the project(Sec 7044,Business and Professions Code:
TM Contractor's License Law does not apply to an owner of property who ALM-DRAIN kVENT W
bullas or Improves thamon,and who contracts for such plojecta with a - ATER(EA) FEE SUMMARY
co,IBIactor(.)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE LJ I am exempt under Sec. B k P C for this reason
E FE
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
WORKMAN COMPENSATION DECLARATION RECEPT N
I hereby affirm that I have a certificate of consent to self-insure,or a FIVrURES PER TRAP SCHOOL TAX Y N
certificate o(W.rken'Compensatlm Insurance ora certl(4d copythermf(Sec. RECEIPT N
380%Lab C.) GAS FA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
TolleyN RECEIVE N
Com S y GAEA.SYSTEMf OVER 4(FA)
CenlBed copy 6 hereby furnished. BUILDING DIVISION FEES
❑Certified copy 6 filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECRFEE
t CERTIFICATE OF EXEMPTION FROM WOR KERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(TM6sectkm-sMnotbecomplated lithe permit 6forone hundred dollars SEINER-SANITARY-STORM EA.200FT. Date Recei t#
(5100)otilyth WATER HEATER W/VENT/ELECTR ENERCYFEE Y N
Icenuftempmthe personeneeof the work forw to this pentylb butuad
1 shag not employ any person In any manner so ss to ct to the
Workers piloonC tion Laws ofG (ornla. Date WATER SYSITM/TREATING PAID
Z O NOTICFIQ rD'I'' ANT:IL agermaking this Certificate of Exemption,you NEW RESIDENTIAL IPLMB. SQ.FT, Date Remi t#
Hshould become aubj;ctto the W.rkers'Compenaatlonprov6lons ofthe Labor
WW Code,you must forthwith comply with such provisions or this permit shall be TOTAL:
> deemed revoked. D I D G 'E
d p CONSTRUCTION LENDING AGENCY SEISMIC FEE
= Z Iher.byaffirm that there 6aconswctlon lendingagenry(or the perform ELECTRIC FEE
O ance ofthe work forwhichth6 permit is Issued(Sec.30W,CIv.C3 TOTAL:
V Ianaera Name PLUMBING FEE
!L F- Lcname Aaare„ QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W IceAilythat l have read th6applicati....d d.mthattheabove Information
IL 6rorrect l agree to comply with all city and county ordinances and mate laws PERMITISSUANCE FEES PAID
r W relating to building construction,and hereby authoriae reprexmative,of this
F— Z city to enter upon the above-mentioned property for Inspection pu rposet. ALTFRORADDTOMFCH.
— (We)agree to save,indemnify an d keep harmless the City of Cu penin. Date RtlCei t#
4.g. habiBI es,in me and expenses which may In anywayacraue AIR HANDLING UNIT(TO 10,000 CFM)
sem City on n en of grantfng of this permit. SUBTOTAL:AIR HANDLING UNIT(OVER IB0BBGF.M) CONSTRUCTION TAXoreIXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:A RD USMATERIALS DISCLOSURE sapplicam Or future building occupant store or handle hasrdous HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date Recei t
I and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOT
❑Yes No
Wlllthe applicant orutcm building occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) �iSSUA�NaC6 DATE
which emit ham mlms air contaminantsss defined by the Bay Area Air
Quality Management District? 'OIL'
R-COMP OHP OR 100,BfD BTU)
Yns "° AUG 8 1992
havereadihehxaa ou.mdeda6requimmnbunderChapter6.95.f BOILER-COMP(OVER 100,000 BTU)
the Califomu Health k Safety Coag Sections 25505,25533 and 25534. 1
understand that if the building does not currently have a tenant,that it 6 my NEW RESIDENTIAL MECFL - SQ}7 P1
ruspomibllity to notify the occupant of the requirements which must be mat CITY Ur kauran I114
prior to Issuance of a Certificate of Occupancy.
Owner or authorlud agent Date
TOTAL: ISSUEDBY:
OFFICE COPY '