21296 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildingProject Identification \5 +.e38,3 PERMIT N21296
Building Address:
C>Q 2 W6\ '�ST�C.1r� Wit.\ \ u I'LL.
Owners ame p one:
eR\ CITY OF CUPERTINO-BU ILDING DIV]ICAL
/d _
• G o-adnre ape: LIc.Ne: APPLICATION / PERMILL
♦7� 4969 BUTLDINC-ELECTRICALPLUMBINGMECHACATEGORY CONTROL#
Amhltect/Engineer. o
1"^ ISS BUILDING PERMIT IN TO
QTY ELECTRIC PERMIT
Address: 'PERMITISSUANCE �1 ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION LIQ
[hereby affirm that Ism licensed under provisions of Chapter 9(comnum APPLIANCESRESIDENTIAL J.BDFSCRn'770N
Ingwlah Sedton7OOD)Of Divisim3 ofthe Busineseand PmfemlonsCode,and my
license isle ful to dd(m. PANELS ^ O�
LlcenseC n Lic.p ��� s t•'a V
Date D _Contra t
ARCHITECPS DECLARATION 211-1000 AMPS
ce00 I understand my plans shall be used as public records. OVERIODOAMPS SQ.FT.FLOOR AREA $/SQ.Fr.
ObE Licensed Professional SIGNSELECTRICAL
re OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
zti .�a Thereby afOnn that l are exempt fromthe Commences License Law for the
following reason!Section 7031Z,Business and Peofesslons Code:Any city or
TEMP.METHTOR POLE INS!.�
county requlresa permRroromtmct,alter,lmprove,demolfah,orrcpalr
anystructum prior to its issuance,alsorequirn theappliant foreuch permit to POWER DEVICES
file a signed statement that he Is licensed pursuant to the proWlom of the
Ou, Contractor's License Law(Chapter commencingwitwith 7000)ofDi
lv-
3 O�n 9( SWIMMING POOL ELECTRIC - -
s thesio3 of basis for
the allege dProfessionCode)violhat ation of exempt therefromby and VAL ATION
0 S the basis(or the alleged exeaithea Any violation of penalty
70H5 by any ou LETSSWHCHESHXIVRCS D
applicant for a permit subjeatathe applicant to a civil penalty o(na marc than
five hundred dollars($500). NEW RESIDENTIAL ELEOTR FT._SQ. TYPE CONSTRUCTION
FlL as owner of the property,or my employees with wages as their sole
a compensation,willdothe work andthestructure is not intended or offered for
sale(Sec.7044,Business and Pmfemlom Code:The Contractors License Law
S does not apply to an owner of property who builds or improve thereat,and
whodocssuch workhimseE orlhrough hisownemployees,provided that such 'GROUT' RFS.UNITS
Improvements am notIntended oroffered forsale.IE howevep thebuilding w TOTAL:
Improvement leaold withinoneyearofe mple lon theowner-bu0derwlll have
le rden of pmving that he did not bund or Improve for purpose of sate.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
L as owner of the property,am exclusively contracting with hicar ed
mntncmn to construct the project(Sec.70/4,Business and Prolamin.Cade: PERMITI.SSUANCE
The Contractor's Linew Law does nor apply to an owner of property who ALTER-DRAIN VENT (EA)
Wilds or Improves thereon, and who contracts for such ptojeats with a - - FEE SUMMARY
cgW(+dor(s)licensed puauant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
U I am exempt under Sec. B k P C for this reason
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
. Owner Date RECF3FT If
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N_
911 hereby affirm that I have a ceninate of consent roself-Insure,ora RECEIPT R
certificate of Workea'Compewtlonlmurance orecertlfled ropy ahereo((Sec. GAS EA. INCA OUTLETS PARK PER Y ' N'
33 W,Leb CJ ,sem —
Pollgp Tf 11 ( GAS EA.SYSTEM-OVER DINGR�EDIVISION
Com any BUILDING DI VISION FECS
MCertificd copy fa heed with the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�Cenifled copy fa filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE' SEWER-SANITARY-STDRM EA.2X1'. Date RCCeI t#
(this stolon need not be completed tithe permit Is for one hundred dollars
(flppotly that
h WATER HEATER W/VFNT/ELECTR ENERGY FEE Y N
I cent thato the person ofthe
so as tobthis became
Weed,
I shall not employ any person In any manner n u ro become eubject to the WATER SYSTEM/TREATING
Workca'Compenatlon Ewe of California.Date PAID
ZZ Applicant NEW RESIDENTIAL PLMB. SQFT. Date Revel t#
O NOTICE TO APPLICANT:ILaNer rtuking this Certificate of Exemptlory you
Fshould become sub)ect to the Work<n'Comperuatlon provisions oflhe Labor TOTAL:
f/9
Code,you=at forthwith comply with such provisions orthfa pemdtshall be l�0
W 9 deemedrevoked. M
LDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE l
CL C Iherebya(Brm that there fa a construction lending agency for the perform - ELECTRIC FEE
7 O once of the worklor which this permit fa issued(Sec 3097,Civ,C,) TOTAL:
Lenders Name PLUMBING FEE
u. 1= Lcndere Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
Icertlfythotlhavemadthleappliationand state that theabove information
O W
IL facetted.I agmelocomplywithall cityand countyordleancesand state laws PERMHI.SSUANCE FEES PAID:
W relannglobullding comtructlon,and hereby authorise represomativesofthfa
F day to enter upon the above-mentlonad property for inspection purposes. ALTER OR AUDIO MECH.
Z (We)agree 10 ave,ledemNly an d keep bared.the City of Cupertino Date Receipt#
V against liabilities,jadgments,cost eand expenses which may in say way amue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
ago me to not of the granting of this permit. AIR HANDLING UNIT(OVER 1Q000CFM1 CONSTRUCTION TAX
I r\ i 10hb�el
Sig.tureofA i fit/Contractor Date EXHAUSTHOOD(W/D(KT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupantslore or handle haaardous HEATING UNIT(TO 100,0DO BTIT) Date Recei [#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
I InIt Yesnd Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTT) TOTAL:
Will the applicant orfuture building occupant use equipment or devices VENNILATION FAN(SINGIX RESID) ISSUANCE DATE
which emit haaardous air conlaMmnts as defined by the Bay Arca Air
Quality Management District? - BOILER-COMP(3HPOR 100,IX0 BTU)
a 4 Yes 9No PA®
haveria lealthhe i Safety
Code Se requirements undernd 255 ,1 of BOILER-COMP(OVIiR 100,000 BTU)
the GBandt Health he building
Coda Sections25505,25S33have
a tenant,that
NOV 021990
respoundernsibility
at ton notify
the oatsdon of the currently avea tenanq that Rfamy NEW RESIDENTIAL METH. SQ.FT.
mor to issuance
cefid Nytheottte of oftherequlmrrentswhich must Wmet
prior 10 Lvuance of a Grtl Ovale of Ottopanry.
Cibl of rpRgr►pep
Owner or aulhorlved agent
Data TOTAL: ISSUED BY'�_ �
OFFICE COPY