23101 4PPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY'
Building Proied Identification PERMIT NQ. 31 0 1
Building Address: j/^'1('I �(/-��'[�,/J�)
����0 h - --" _ - Ar c'uVIrtUN SvuN....A�JA.e
-uwncrs eons: 1
1715� +r�,9S OV6 4/.57/2_ CITY OF CUPERTINO-BUILDING DIVISION 4Z_/S-9f I
cnntraanraName: n �nLlc.N.: APPLICATION I PERMIT
ioobrrt�Alc�y fns-rcpt BUILDING-ELECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL
tt grocer: I Lk.Nex
�' ELECTRIC PERMIT', t FEE t', d, BUILDING ERMITINFO .I
Addross: `I PERMITISSUANCE ` lilt
LICENSED CONTRACTOR'S DECLARATION I MpEANCE4RFSTDENTUL OB DESC TION
IherebyafftsntlutlamltcenxeduMerp Ialan of Chapter 9 cl
Ingwlth SetUOn7 1100)of Dlvlelon3 ofthe Bull ,coact rofeulonrl�—,and my PANGS
Ilcense is in lull and effect. 1✓Vim_ U
Lice Class Lk.N — L�7Q7 �Tp
Dal el.Ll.���._ConHactor 301-1 A1111>S S •
ARCHITECT'S D R O
OVERIWOAMPS - I SQ.IT.FLOOR AREA S/SQ.FT.
pppppppp!!!!aO Zp lundentand my plate ehallbe usN as public records - I
Licensed Podeaskrul SIGNS ELECTRICAL 1r _,
<<� OWNER-BUILDER DECLARATION I SPECIAL CIRCUIT/MISC - L F171, If V
Ihereb alBmnthal l am exempt orm the Contractor's License Law forth, f II
O O following reason,(Section 7031.5,9u,iness and Pmfemlom Code:Any city or /TEMP,METER OR POLE INST. -/ li V M �'� 11
county which requlma permit W mrutrumaiter,improve,dmnlbh,orrepafr / aR
inystrodo-pdue to R Slsasance,aborequlreatheappll,ant for such perninto pOWER DgWCpS
L'T1 file a
signed statement that he b licensed punuant to the proZh of the I t f
Owl ContrattoraLicerae Law(Chapter9(commencing whh Section 7tX1D)ol Dlvi- SWRxIMING POOL ELECTRIC JJ'I
30 sion3 of(he Businmand Professions Code)orthat hebeumpt therefroman^
Sn the Weis for the alleged exemption. Any violation of Settlon'7031.5 by any OUTLETSSWITCHESFIXTURFS
sppllczm fora pe ants. jetty theapplkiiM toy civil penaly o(not rrorethan '
a live hundred dollars(5500). NEW RESIDENTIAL ELECTR__SQ.Fr. STORIES TYPE CONSTRUCTION'
I,as owner of the property,or my employees with wages as their sole
�7rda compensarion,wilidothe work,andthostructure b not intended or offered for -
F`q
sale(Sec.700.1,Buttress and FrofmWN Code:The Contractors LimmeIA 3� does not apply to an owner of property who builds or improves thereon,and OCC.CROUP RES.UNITS
wh.docs suchworklumself.ditrough lu...employees,provided that"
Improvemenb are not Intended oroffered foreak.If,however,thebullding or TOTAL:
Improvementasoldwithnoneyearofcompleiogtheowner-buRderwdl l - r, -, � �l '
th rden of proving that he did not build or Improve for purpose of safeJ. QTY. "+ :%PLUMBING PERMIT MI , 'S•EE�i FLOOD ZONE APN
�I,as owner of the property,am exclusively contraGing with it it PERMIT'IS6UANCE L,
rontradon to rorntruct the project(Sec.7044,Businmand Professions Code:I /+ ..+
no Comments License Law does nu apply to an owner of property Who 7 ALM-DRAIN&VENT-WATER MM -
builds or Improvn tbeneon,and who contracts for such pioleds with a %,FEE SUMMARY,;f 0 'I
c�([.doK. Bre,ted pursuant to the Cdntraclora License Law. BACK FLOW PROTECT.DEVICE I �w
L,J I am exempt under Sec. 'B&P C for this mason I nUrS\f)p Fsss I
Owner - Date DRAINS FLOOR ROOF,AREA,COND. '� (SANITARY Y T
RECERT M
' s WORKMAN COMPENSATION DECLARATION nurv.NRpS PER TRAP lw.f1 SCHOOL TAX Y_ N_ -
❑I hereby affirm that I have a certi0ote of consent to self-fir or a CC--�'�•' (06D RFCEIPT N
certlflole ufWark,ni Compemtlonlvurance oracertilled copy thereof(Sec GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y' N
3801,Lab C.) RECERrrN
Pol Icy 8 GAS EA.SYSTEM-OVER4(EM - BU j. DIVISION FE P,. I
Coco any CY-b( . C'O 11l�77((''
[�Ce Uled mpy is hereby fumisFed. CREASE/INOUSIRL WASTE INTFdRCEPTOR PLANCHEC .
WQ�e1Bed copy b filed with the city IwpecHon division.
CERTIFICATE OF IXEMITION FROM WORKERS' CREASE TRAP PAID'
COMPENSATION INSURANCE' SEWER-SANIHARY-STORM EA.4(IOFT. Date RCtieipt#
(TMs section need our be completed Bthe permit L for one hundred dollars
(5100)orlmd WATER I TEATER W/VENT/EDCTR ENERGYFEE Y_ N_
I ormly that in the perfoonummolthe work forwhich this permit is nutted,
I shall not employ any person In any manner m as to become subject to the I WATER SYSTEM/TREATING - PAID '
Worken'CompenaaHon Lawsof CaRfomla.Oat, _
* Z Applicant NEW R75IDpN17AL PLMB. SQ1T. Date Receipt#
Z G NOTTCETO APPLICANT:If,after making this Certlfcitenf Evemption,you
should became ash}t to the Warken'Cnmpnnaatlon pravlsbtu o(the Labor TOTAL:
Code,you most forthwith complywith such provielorsorthisperrrdtshalibel 'BUILDING FEE
� > deemed revoked. I SEISMIC FEE I
(L — CONSTRUCTION them 0 a ors LENDING AGENCY
M C Ihereby .,kf.h. ihhth amn+itunlonb(Sl .3 agency 7,Cl h. .I pedorrm Op � (ELECTRIC FEE
0 Z an ce of the workfor whkhthb permitk4sued(Sec.3097,CIv,C3
U O Iznder'a N" . , .,. , PLUMBING FEE
LL t- Lenders Address - QTY.' MECHANI_CAL�PBRAT' '1. . `rI'EE S!I MECHANICAL FEE _
O W ' Icedi/ythat l haveread this applicatienand statethattheabove,Information l (FEES PAID:
tecorrect.l ageretecomply with aL city and county ordinances and state lawn PERMITISSUANCE
T 6 relating to ilding construction,and h by authmbue representatives of 1
F.. N citytoente uponthe ovcmenllo perry for impecdon purposes. AI.T7IIR OR ADDTO MECH.
U) Date Receipt#
V Z (We)a e to save 3ndem 0y d ep harmless the City of CuNdlno AIR HANDLING UNIT(7010,1X10 fFM)
agalnstlU IIItIca,Iud rate,core ode penis which may In anyway sansei SUBTOTAL:
agalns sal city aequenceo granting of this permit. CONSTRUCTION TAX
�sp Gt. R 1 AIR HANDLINGUNR(OVERIO,OWCFM) ,'
Slgw ppl can on ra r Dan EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOU MATERIALS DISCLOSURE - - -
Wdltheappliczntorf uture building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) I Date Rece1Dt#
material as defined by the Cupertino Municipal Code,Chapter 9.1 4,and the \
I lcaltls and Safety Cod ctlon 2S534(a)T HEATING UNIT(OVER 1010,000 BTU) I TOTAL;('
❑Y. x No -
Will the applicant future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) pISkj NNJE DATE
which emit hazardous air contaminants as defined by the Bay Ams Air B- �a ee N
Quality Management Dist tt7 BOILER-COMP QI{PDR l00,fXX1 BTU)
;. Y No
46ave eadlealthA uemleriabrcqul25SaS,sunder d2553r6.95of BOE.ERCOMP(OVERlW,000811) DEC 16 1991
the Callfo nla Health Srfety Code, Ions 255(15,21533 and 25511. 1 -_-
under,Dvil
that if th building does of ncntly haveatenant,that ltbmy NEW RESIDPN77AL MECti, SQ Fr
responslb)Ity to noif theoavpan o ercqulrements which must be met CITY ur VUNCMIB
grin oi_ o! Certificate of 1-panty. : __
Own Rho Yv �ISSUEDBY:_
� 4 TOTAL: '
OFFICE COPY