23371 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildingPr 1 kalian PERMIT NO.
V ng Address Z� Qov:koF-Iva 23371
one:
CITY OPPLICTTNION / PEE DIVISION ���
G°^�;°r,�Name: 5� Lk.Na: APPLICATION 1 PERMIT
IS�Y BUMDINGdECTMCAGPLUMBINGMECHAMCAL CATEGORY CONTROL p
Archltad Engg ` Lie.N.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE ❑ O ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am liceeaed under provisions of Chapler9(common. APPLIANCESRESTDENRAL BDL K[1'I'I0N
ingwithsaction aDlvhhegualnessandProfessloneCote,and my
limmeuimfullforecanddfect. PANES
License Cien
Yy�
LIGX
Date Contractor
ARCHITECT`S DECLARATION 201-1000 AMPS
rn Is I understand my place shall be used as public records. OVER TODD AMPS SQ.Fr.FLOOR AREA f/SQ.FT.
�GCel z�j Licensed Professional SIGNSELECTRICAL A L E
6 OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC n n
(here affirmthat l am exempt fromlhe Contractors Llcenx Gwforthe IV�
following reason.(Sedion 70715,Business and Profession,Code:An tl or
4i i. TEMP.METER ORPOLE INST.
P� countywhlch requBsapermlhroroetruct,alter,lmprove,demoWh,orrepdr G/!
zbr IN
o Y 7'
g any structure prior to its issuance,also requires the applicant for such permit to POWER DEVICES A E
G file a signed statement that he Is licensed pursuant to the provisions of the
Contradoes License Law(Cha pier 9(mmmenclag with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
H�OJ slon3o(the Business and Proru
(esskCxm
ode)orhhat he therefroand
X77 the ba,b for the alleged exemption. Any violation of Section 70315 by any
p« applicant for a permit subjectstheapplkant to a civil penalty of not stn.than OUTLETSSWTTCHESFI%TURES
a five hundred dollars(f500).
NEW RESIDENTIAL ELECTR
�n ❑I,cue owner ofthe p wuxl property, employeswith Wages r offered
�'�' STORIES TYPE CONSTRUCTION
rompenstlon,w0ldothe wwkand thestrocture knot Intended car offered for
O sale(See 7064 Business and Professions Code:The Conlractat,License Law
$$ dos net applyto an owner of property who builds orlmprovs thereon,and EEE OCC.GROUP RES.UNITS
whodocasuchworkhimxiforlhrough hkown employes,provided that such
Improvements are not intended oraffered ferule.If,however,thebuilding or TO
Improvement b.aid withooneyearofcompledon,the owner-bullderwlll have
ttlekurden of proving that he did na build or Improve for purpose ofuk.). QTY, PLUMBING PERMIT FEE FLOODZANE, APN
u L as owner of the preperty,am eadusively contracting with licensed pp((,(L(.ISSUANCE
contractors to com/ruct the project(Sec.7064 Business and Professions Code:
The Contndo/s License LAW dos not apply to an owner o6 property who ALTER-DRAIN 4 VENT-WAlII((EA)
builds or Improve thereon, and who contracts far such pkojecm with a
cc actor(s)Ilunxdpursuant to the Contrador'a Llcenx Law. FEE SUMMARY
Ll l am exempt under Sea. B&P C for this xamn BACK FLOW PROTECT.DEVICE
OUTSI Fuc
DRAINS FLOG ROOF, SANITARY Y N�
• Owner Date R AREA,��' RECEIPT X _
WORKMAN COMPENSATION DECLARATIONFIX
by
SCHOOL TAX Y N
❑I hereby afllrm That I have a certlBute of cmxm to self-Inare,u a RECEIPT X
certiflcabC.Workers'Compevallonlcuursnmuacertified copythereo!(Sx. GAS,F.A.SYSI.FM.1 WC.60UTLETS PARK FEE Y N
3800,Lab C.)
Policy p f X
^y S RR GAIA.SYS EM.OVd(EA) DBUILDING
INC DI VISION FEES
stifled copy is heed With the
city GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CedlOed ropy b filed with the dry Impectlon division. '
CERTIFICATE OF FXETI PFION FROM WORK ERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWFWSAMTARY-STORM EA.200Fr. Date Recei t#
(This section neetl not becompleted If the permit kfor one hundred dollen
($100)oify that
WATER HEATER W/VENT•/M FCTR ENERGYFEE Y N
Iceam employ
say
ypehe oon I.any
fo as to
pennjecttoit is heed, —
1 shag not employ any.Leon in any manner so x to become subject to the
Workers'Compenution Lsva ofGWWATER SYSTEM/TREATING
Applicant omb. Date PAID
O Z ApplNEW RESIDENTIAL PLMB.__SQ.FI'. Date Recei t#
Z O NOicant APPLICANT:If,after making lisle Certificate of Exemption,you
should become subject to the Workers'Compensation previsions of the Labor TOTAL:
H3
Code,you=at forthwith comply with such provisions or this permit shall be
] deemed revoked. B ING FEE
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
O. IhcmbyafOrmhhat them les a commiction lendingagency forthe pedorm- ELECTRIC FEE
D Z ane ofthe workforwhlch that permituC.) TOTAL:
is Ised(See.3097,CIv.
o O Tender.Name PLUMBING FEE
IL F LendersAddre.a QTY.qF
ECHANICAL PERMIT FEE MECHANICAL FEE
O W 'Icedltylhatl have read thbapplicalinn and state hhattheabove information
IL Isrorrcct.Iagrceto comply With all tltyand muntyocdlnanmand state laws SSUANCE FEES PAID.
} N relating lobelldingromwdion,and hambyaulhorlu reptnentalivesofhhb
H Z citytoenlerupon the above-mentioned property for inspection purposes. ADDTOMECH. Date Rotel t#
— (We)agree to save,indemnify an d keep harmless the City of Cupertino P
against liabilities,pd ,costeantl expenses which may In anywayamrve DLING UNI IT010,0DO CFM) SUBTOTAL•
agaimt uld 1 unce o(theIngof-hla permit DLING UNIT(OVER IO,MOCFM) CONSTRUCTION TAX
Si here of Applicant/Contrador Da HOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willtheapplicant ortumre building mmpmtstore or handle hazardous UMT(T0100,000 BTU)material as defined by the Cupertino Municipal Code,Chapter 9.12,and the _ Date Reaei t#
Health and Safety Cade Section 25532(a)7 UNIT(OVER 100,000 BTU)Ys No
Will theapplicant ce hiturobllding occupant use rqulpment ordevices ION FAN(SINGLE RESID) ISSUANCE DATE
which emithtandousair contamluntsas defined by the Bay Area Air eQuailtyManagementDistrict? -COMP OHP OR 100,000 HIM MAR 1992
q Yen No
have mad the hazer ou,malerials requirements under Cha pier 6.95 of BOILER-COMP(OVER 100,000 BN)
the California Health&Safety Code,Sections 25505,25533 and 25576. I
understand that lithe building does eat currently have a tenant.that It k my NEW RESIDENTIAL MECH. gQPT CITY of wr CnuivU
responsibility to notify the mcopant of the requiemenle which at be met
Prior to bsuance ole Certificate of Occupancy. �'\��./ya}���
Owner or authorized agent Date ISSUED BY: �a�r /
TOTAL:
OFFICE COPY