23750 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES-m USE BALL POINT PEN ONLY
Building Pro'ed Identification PFRMIT NO.
Building Address:
a .3b�-�► D( �� 23750
fFrPf I�UW`PVT�(�_. an
CITY OF CUPERTINO-BUILDING,DIVISIO,N .
aNa^e: /� /J 7 Q"Lie.N°: APPLICATION I PERMIT 7 Ylr—1
vIZ
Core : A9—t — � J�I !S �BUILDING-ELECTRICAliPLUMBING-MECHANICAL a CATEGORY CONTROL p
• Archited/Engineer: -Lic.Nex
C'7 " +�' cc _ Qiti t;��+tit Bir&C'S'RI�PkRMIT , t`FEE ::. `�UII..DI-"C.PGRMIT:INFO
Address: vD JC PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affivethat I am licensed under provisions of Chapmr9(comment. - APPLIANCES-RESIDENTIAL JOB DESC ON
ingwith Se on7000)of Dlvlsim3ofthe Busiusand ProfegslonsCode,endmy '-
time.is in full force and effect.' PANELS
I5S
License Claes Lnot . i
Date�Contradol' -R
ARCH] 201-10W AMPS
-ARCHITECT'S DECLARATION _
N
p�2 I understand my plans ehalf he used a public records. OVER 1000 AMPS ;'SQ.FT.FLOOR EA $/SO.FT.
p��uu SIGNS ELECTRICAL 1
� _, E0_ ITV .
Licensed Professional - 1°
OWNER-BUILDER DECLARATION
SPECLILCIRCUIT/MLSC
F, a IherebyatBmthat I am exempt from the Contracter'sLi¢nee Law for the '
2 O... following reason.(Section 70115,Business and Professions Code:An city r
Y 7'° TEMP.METER OR POLE INST. "4u✓ �✓a.�' • ^�
p O anystm mpAorrequlrestoiU a rat e,aLso ruui,mstheaet.alter, provgdemouch,olrcpair _
Y any atmduretatc.coltshat he Is alcensed pursuant
to
the
revisions of to ppyyBg DEVICES
file a signed statement that he V licensed pursuant to the provblow of the -
3w�y Contractor'sLicense Law(Chapter 9(curementlng with Sectio 7000)of Divi- SWIMMING POOL ELECTRICDATE
1,
EO� slon3o(lhe Business and ProfessiomCade)orthat he lsexempt thercfromand1 VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any
oapplicant for a permit subjects the applicant to a civil penalty of not room than OUTLE'ISSW1TCIiESHXTURFS
five hundred dollars($500). - NEW RESIDENTIAL ELECTR
j F-11,as owner of the pmpsrty,or my employees with wages as their sole SQ'FT. STORIES - TYPE CONSTRUCTION
mpensation,wBldothe work andthestmenon Isnot Intended or offered for
O sale(Sec.7044,Business and Professions Code:The Contractors License Law
does not apply to an owner of property who builds or improves thereon,and
- who doessuchwork himself orthrough his own employees,provided that such OCC.GROUP RFS.UNITS ,
Improvements are not Intended°roffered forsale.If,however,theta ilding or TOTAL: -
Improvementlssoldwithlnomyearofcompletb theowner-bullderwlll have '
t e of proving that hedid not build or Improve for purpose of sale.).
PI:UMBING.PERMIT +tt t, �!FEE71 FLOOD TONE pPN
Lben L as owner of the property,am exclusively contracting with Ilcensed PERMIT ISSUANCE
contractors to comored the project(See.7044,Business and Professions Code: ✓
The Contractors License Law does me apply to an owner of property who ALTER-DRAIN k VENf-WATER(PA)
Wilde o1('proves tpursua and who contracts for such p.ok I with a ( ,."4' t BE$•$UMhfAR.Y`.t+ + -
�,3Lt[acam exempt
der Sm.nt Mthe Contractor's Llcenae Law. ' BACK FLAW PROTECT.DEVICE
. LJI am exempt under Sec. B A P C for this reason � '
DRAINS FLOG ROOF, SANITARY" Y N
Owner Date A AREA,COND. RECEB'C N
WORKMAN COMPENSATION DECLARATION
*.
01 hereby affirm that I have a certificate of consent toself-insure,orpl%'IVRES PER TRAP SCHOOL TAX Y N
a RECEIPT N
certificets mWorer
ksm'C°ropaidum Insurance or aiertifed copy thereof(Sec• GAS EA.SYSTEM-1 INC.40UTLETS
3800,Leb C.) PARK FEE Y N
Poliryp GAS FA,SYSTEM-OVER4(EA) RECEPTX '.
Cu any. BUILDING DIVISION FEES
�ined cepy is hereby furnished. GREASE/LNDUSTRL WASTE INTERCEPTOR PLANCHE-CKFEE
ertNed mpy la need with the dry inspection division.
'CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID -
COMPENSATION INSURANCE SEWER-SANITARY-STORMEA.200FT. Date Rccel t#
(Thos section need n°t be completed i(the permit V(Drone hundred dollars
($1I0)orlces3 WATER HEATER W/VENT/ELECTR ENERGY FEE Y - N
Iartifythat In the pedormance°lthe work forwhlch this permit is issued,
I shall not employ any person In any manner se,as t b mg ed to the WATER SYSTEM/TREATING
Works.'Compensatlonlwe forma.Date __ etL _ PAID
Z Z Applicant- - /,, - NEW RESIDENTIAL PLMB. :,OFT. Date Recel t#
Z O NOTICEco I. esubje he anermakingthbeation ceteofons oft eLabo
should you
asubjecttothe Workers'Comprosialns or
rthin permit shall
Labor TOTAL:
� N Code,you mustforthwllh comply with such provislow orchis permit shallbe BUILDING FE ,
deemed revoked.
W — CONSTRUCTION LENDING AGENCY 2ELECTRICFEE
EE
a ]hereby etfirm thatthere laemnetmctlon lendingagenry(orthe perform- F7 O ance°fthe workfor which this permit la Issued(See 3097,Civ.C.) '' T aL andere Name G FEE'U. I— LendersAddrcaa QCY . iviBGHANICAL P�RIv1IT i''FEH`'' ICAL FEEOW Icertltythatl have read[hlsapplicetfonand atatethattheabovelnforrration Iscorred.I glosetocomplywith all cityand countyordennces and state laws PERMITISSUANCE �• :relating to building construction,and hereby authorize representatives ofthis - .city to enter upon the above-mentioned property for Wpection purposes. ALTER OR ADDTOMECH.
(We)agree to save,indemnify an d keep harmless the City of Cupertino Receipt#' '
V . against liabilities,Judgments,mess and expenses which may in any way accrue AIRHANDLLNG UNIT(TO 10,000CFM) SUBTOTAL:
against said City In mosespence of the granting of this permit.
" AIR HANDLING UNIT(OVER IQ000CFM CONSTRUCTION TAX
Signature of Applicant/Contractor Date" - EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE ' -
Willtheapplicantorfuturebullding occupant simmer handle hazardous HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date RCCei f#
Health and Safety Code '.25532(.)7 HFATING UNIT(OVER 100,000 IHU) TOTA �~
7,Yes No - -
Will the applicantorfuture,building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air -
Quality Management Di�shcJY _ BOILER-COMP(3HP OR 100,000 BTU)
PI Yee I yt'No t ,
h nia Healthe h
a sus materials reons 25Sntsundernd 25516.950( BOILER-COMP(OVER 100,000 BTU)
theerstadt Health building
Code,es otcurre25505,ve a tenant,
understand that if the notify
the ocmpoea notcurrentlyhavea/hich that It met NEW RESIDENTIAL MECf7. . SQ.FT.
responpriori issuyto Of a Ctheocmp.ntofthepa requirements which must be met
prior col saM of Occupancy.
owner or auth rued agent Date as,. . ISSUED By `�� • a
OFFICE COPY