23329APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pro'eo Identification
PFRMITNO,
B°40 ter/ r6u;w 4-3
23329
one.
A A A
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
^ -2,6
O
2, L
a C °:•"' ° LIc. No:
BUILDINGELECTRICALPLUMBINGMECHANICAL
CATEGORY
CONTROL X
A iteet/Engineer, Lie. No:
QTY ELECTRIC PERM T FEE'\
BUILDING PERMIT INFO
Address:
PERMETISSUANCE
�:j ❑ El
I_F�
CONTRACTOR'S DECLARATION
Ihereby affirm that l son licensed under provisions of Chapter 9(comment
ingwith Sedion7O0o)of Dfvf m3ofthe Rusin and PmfessionsCode,andmy
lice.. is in fuI torte and died.
APPLIANCES E
JOB DFSC ON
�j a L+ j�
PANELS
Licenx Clea Lic.
O l
,4,7 {�I0
Date Contndor
ARCHITECT'S DECLARATION r,
]understand my platy shat be used sat public records. p
�
�IL
AMPS
ER 1000 AM
SQ. Fr. FLOOR ARG
$/SQ. FT.
Llrnnxd Profealoml )1
OWNER -BUILDER DECLARATION 1
I hereby affirm that I am exempt from the Contractor'.Licenx Law forthe
SIGNSELEC
SPECIAL C T/MLSC
Xp-��
LED D I N
TFAIP.MEITR OR POLE INSI. (�)
IDWF- I7 FS
following reason. (Reeler, 7MI5, Buslnea and Professions Code: Ary cityor
countywhichmquimsapermittommtrod,alteplmpm ,demolish,orrepair
anystrocture pdorto its issuance, also requlresthe applicantfonuch permit to
file a signed statement that he ls licensed pursuant to the provlslom of the
Contractors License Law (Chapter 9 (commencing with Section 7") of Diel-
don3 of the Busimax and Professions Code) mffiat he h exmp"herefrom and
the basis for the alleged exemption. Any violation of Section 70315 by any
ppB tfora PerMteub)ecb theapplicanttoacivilperultyofnotmoretban
X.
pE
9
G-�
SWIMMING POOL ELECTRIC k
I�4
/ OUTLETSSWITCHFSHXTUR29
TION
�B
NEW RESIDENTIAL ELECTR �'hT'
e ns owner of
I, a• owner of the property, or my employees with wages as their sole
property,
STORI
TYPE CONSTRICTION
sat044, will do
workand the structure is net Intended oroffendfor c
Business
lc( .7064, Business and Pro(ealoro Code: The Contractors License Law
TOTAL:
QTY, PLUMBING PERMIT FEEF100D
PFRMI7ISSUANCE r
ALTER -DRAIN & VENT - WAhR (EN
does not apply to an owner a property who Wilds or improves thereon, and
whodo suchworkhimselforthroughhlsownemployees,providedthatsuch
Improvements are not Intended mattered for xle. If, however, the W Ilding or
improvement b wtd within oneyearofcomplefom the owner-bullderwill have
th,il�umxn°f proving that he did na Wudorimpeavef°rpurposeofsale.).
L, f { as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Businea and Professloru Code:
The Contractor's Licenx Law don not apply to an owner of property, who
W ilds or Improves thereon, and who contracts for such peefeds with a
Law.
c,O.t et (a) licensed pursuant to the Contractor's License Law.
LII am exempt under Sec B & P C for this reason
OCC.GROUP
RES. UNITS
ZONE
APN
BACK FLOW PROTECT. DEVICE
SUMMARY
Owner Date
-Y) , WORKMAN COMPENSATION DECLARATION
ul hereby affirm that I have a certificate of consent to self -Insure, or a
DRAINS FLOOR ROOF, AREA, ODND.
SANITARY Y_ N_
RECEIPT
FIXTURES- PEA TRAP
SCHOOL TAX Y N —
' mrtificeteof Workers'Compensatimil mncemacedifkWmpythereof(Sec.
3800, Lab C.)
Policy X
RECEIPT#
GAS EA.SYSTEM-I INCA OUTLETS
PARK FEE Y_ N
RECER•T N
Com any
ed copy is heed with cit.
❑ CertUed copy ls filed with the city irepection division.
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section need not Ix, completed If the perm t ls forom hundred dollars
GAS G.SYSIT:M-OVERd(G) 15'—'.1
GREASE/WDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
PLANCHECK FEE
PAID S
Date Recei pt#
CREASE TRAP
SEWER -SANITARY STORMG 200FT
0100) or In..)
lhe workmanner for which this permit b Issued,
I ¢notffify that in any perhe son in any
I shall not employ any person 1r, any manner w n to become subject to the
Workers Compensation Laws of California. Date
Applicant
NOTICEco APPLICANTesubje subject
.her rs'Co per .tion rateofons of the you
should become subject to the Worker,' such P rwuon pmvhis p of the Labor
Code, you =at forthwith comply with such Providers or this permit shall be
deemed revoked.
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N —
PAID
Date Revel t#
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. SQ}T.
TOTAL:
BUILDING 'E Q
CONSTRUCTION LENDING AGENCY
I hereby affirm that there etrodlon ry
agenfortheperform-
anrnof the work for which this permit '.issuedId (Sec. (Sec. 3097, Civ. C.)
Lenders Name
Lender's Add.-
SEISMIC FEE
s
QTY. MECHANICAL R
PLUMBING FEE O ^
thatH
IcerttfythatI
edmat
MCU Nf ^-E
alatbnandftyand unty ordinances
lsrorrect. l agreetocomplywfth andhembya thomm inanaband mate
town comply laws
citytoet° uponthea rudlon, and herebyauthorlu representatives of this
city toe or Pon the above ntloned property for inspection purposes.
BV . e i save, ma f4, an d keep harmlea the City of Cupertino
agai Its 11 s d espenseswhichmayinanywsyscome
ag.' t neon' en t gramingofthigpermit.
PIRMTT155UANCE
ALTERORADDTOMECH.
AIRHANDUNGUMT(r010,000CFM)
�ES PAID: G�9Y
Date Receipt#
SUBTOTAL:
AIR HANDLING UNIT (OVER lo,BoocFM)
CONSTRUCTION TAX
igrutureof AppBcent/ netndor Date
HAZARDOUS A -RIALS IS SURE
Willtheapplicant rfuture ngercupan oreorhandlehazardous
aterial as drti
mDate
efined by the CuCupeno Municipal Cade, Chapter 933 and the
EXHAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
Recei t#
HEATING UNIT (TO 100,000 BTU)
I lealth and Safety Cale Sed25532(.)7
❑ Ya o
HEATING UMT(OVER 100,000 BTU)
TOTAL:
ant or
ture
Willtheepplirousair contaminants.ccu oodby the Bay Area devices
equipen
which emh applicomah contaMlding occupant
ccupy Luse the Bay Area Air
Quality Management District
Yn o
VEN'UGTION FAN (SINGLE RESID)
1$$IJA,{11� �ATEe
p7 %(
BOILFR-COMP PHP OR IOO,IXq BTU)
,❑
' l hveread the haze ous materials requirements underChapter 6.95 of
the Glaifrn lealth&Safety Ccde,Sedims25S05,75533 and 25534. 1
BOILER-COMP(OVER 100,0X0 BTU)
NEW RESIDENTIAL. MECH. SQ.FT,
I
undentan thtifthebuildingsnotcamrntlyhavea tenant,thatitlsmy
rapers; lity on ifythe ate a requirementswhich Stho
prior rtlf sof panty.�Y
70
FE
["
Y ,�4 My'y['�LRIIisV
VI -4 lzVl-tI1111Ve1
�OrI�1CCI
nc or au oriud a an es
TOTAL:
ISSUED B
J
1
OFFICE COPY