22811 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: Vi 0.. %w C7 , 22811 2 n rI aI
2aal GG�j{I I I
rens ams: one:
W NO 3l-'— y < i CITY OF CUPERTINO-BUILDING DIVISION
Cotad°t['.Nj^ J R Lie.No: APPLICATION /PERMIT
Gaal t + oP_N[A' PAI 'O ✓Vt I S BUILDING-ELECTRICALPLUMBING-MFGHANICAL CATEGORY CONTROL p
Architect/Engineer. ' Lk.No:
��/2��79 m ( QTY ELECTRIC PERMIT FEE -BUILDING PERMIT INFO
Addresa:46 C au 'J/SyJ'
PERM[TI55VANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ihe..bydflrm that lam licensed under provisions of Chapter9(commene- APPLIANCESRESIDENTIAL JOB DESCRIPTIONIngwith Sedlon7000)°f Division3ofthe Businemand Pmfesslons Code,and my
Lice )sin(uI dmired' ��`/� PANELS
License Cl Lk.M
Date' O Contractor urn. a �V" O ANTS
ARCHITECTS DECLARATION 19,, } 201-1030 AMPS
W F2_ I understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREAod . .
Licensed Professional 9GNS ELECTR CAL da
I N A L E D
f 6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MSC a.y tt A
z9 )herebydermthat lam3l.5,B fromthe Contractors Code;LawAny for the ,® 1\V!'
oo following rearm.iSection 70315,Business and Professions Code:My city it
O Z"'� TEMP.METER OR POLE)NST.
PIJT ; R
P t' county which requlresa perodt to for such prrepalr
°� any structure statement
aior to temenb that
he tat alcensed rersuant to the provisions
of t e ' '� 2
�a
file a signed statement that he V licensed pursuant to the proWloru of the POWER DEVICES PATE
3O� Contractors License Law(Chapter9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
sion3 of the Business and ProfessionsCode)orthat he is exempt therefromand VALUATION
G6 the Wale(or the alleged exemption. Any violation of Section 7031.5 by any Q, OUTLETSSWITCHF&FIXTURES OQ
O applicant for a permit subjects the applicant to a civil penalty M not more than
live F]1,as owner of thepro NEW RESIDENTIAL ELECTR SQ.IT. STORIES TYPE CONSTRUCTION
..�n ❑1,as owner will
the a work,and
or my employees with wages r thele sok
compensation,044,wilidothew Professions
Code:Theure is
ContraIntendctors
profferedfar
sale(Sec.apply
to alnowner
ami f property
Code:The Contractors Llceve Law
$$ does not apply toanicoulo(prough iso builds
mporimproves ees,prvided roes,and OCC,GROUP RIS.UNITS
who does such nts am khimsended orwgh hlsowne.If,ho es,however,
the
d that such
improvements are not intended oro(fered!create.I[however,thebullding or TOTAL:
Improvementbsold within oneyearo(completloMtheownervbullderwlllhave
thgE*rdenof pmvingthat he did not build°rlmprovefor purpose of saleJ. Cry, PLUMBING PERMIT FEE pLOOD ZONE APN
U 4 as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE .
contractors to construct the project(Sec.7014,Business and Professions Code:
The Contractor's License Lew does not apply to an owner of property who
ALTER-DRAIN k VENT-WATER(EA) -
builds t r Improves thereon,and who contracts for such p.ojects with a
coRlpactorW exempt
under nt
the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEESUMMARY
LL��I am exempt under Sec. B k P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPT p
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAX Y N
❑I hereby affironorke.that 1 have o lk cone of consent d self-insure,pyth.m.f ora RECEIPT M
38001tabC.) rkera'C°mpersatlon lrsuren38 ora cerd(led copythereof(Sec. GAS F.A.SYSTEM-1 INCA OUTLETS PARKFEE Y N
3800,Lab CJ '
Policy p RECEGAS F.A.SYSTEM-OVER 4IRA) DING DT x
Company BUILDING DIVISION PEES
1_ICeklfied copy is hereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
ertifted copy is filed with the city inspection divlsion.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANffARy-yTORM EA 200F,• Date Reeei [#
Uhlssedion need not La completed If the permit Is forone hundred dollars
(8100)orl
138k1(yththatlnthe performance of the work forwhich this penult is Issued, WATER HEATER W/VENT./ELECTR ENERGYFEE Y N
I shall not employ an/person in any runner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of Cali(ornla
O Z Applicant -
iNEW RESIDENTIAL ELMS.__SQ.FI, Date Recei t#
Z O NOTICE TO APPLICANT.If,afler making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of Labor TOTAL:
f0 Code,you must forthwith comply with such provisions orthb permit shall be UI LNG s
III j deemed revoked.
d c CONSTRUCTION LENDING AGENCY - SEISMIC FEE
I hereby affirm that there Is a consbuction lending agency for the perform- ELECTRIC FEE
Z ance of the work which this permit h luued(Sec.3097,Civ.Q TOTAL: s
V O Landers Name PLUMBING FEE
LL F Landcrs Addresa QTY. ' MECHANICAL PERMIT FEE MECHANICAL FEE
OW I38rilfythatl have read this application and date that the above information
IL Lacorrect.Iagreeto complywithallcityand countyordinancesand nate laws PERMIT ISSUANCE FEES PAID:
} relating tobulldingerutrudion,and herehyauthoriae repressntall...u"'
(— Z dtytoenterupon the above-mentioned property for inspection purposes. ALTER OR ADDTO MECH.
(We)agree to save,indemnify an d keep........--iv o(Cupekino Date Recei t#
V a gaimtliabilhics, dgme m,rodeandexpenwswhtchmayinanywayamme AIR HANDLING UNIT(TO 10,000CFM)
SUBTOTAL:
against Ciry neonsVuence or thnting of this pemdt ,.
,� Z AIRHANDLINc uNIT(OVER 10,000CFM) CONSTRUCTION TAX
Signatureof Applicant/Conte roe Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZAR US MATERIALS DISCLOSURE
Will the applicant or fu re buidingoxwpant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.1$and the _ Date Recei t#
Health and Safety Code Sedlon 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes No
Will the applicant demo,building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
. Qu a lity Management District? BOILER-COMP(3HP OR 100,000 BTU)
4 Yea q No
Yes
read the haza pus materials requirements under Chapter 6.95 of BORER-COMP(OVER 100,000 BTU) �®
the California Health k Safety Code,Sections 25505,25533 and 25534.I'
understand that ifthe building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. S"FT' OCT
responalbllltywrotl(y t a ,)ant of the requirements which moat be rent 1 QO
prior to im fa tific QOccupancy. 1 1991
Own orized gent 10 Data 9
' TOTAL: ISSUEDB1"�� �Ca
OFFICE COPY