23051 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — LISE BALL POINT PEN ONLY
Building Project Idemlfleatlon - _ PERMIT NO.
BuBtling Addresno. S3Z � 6LAN.-r Av£ - 23051
�r. one.
{Me5 MATJjf:Lj AAAO q-/33EI CITY OF CUPERTINO-BUILDING DIVISION
Contractor.Name: Lic.N. APPLICATION / PERMIT - I -N
u AV BUILDINC—ELECTRICAL PLUMBING-MkHAMCAL CATEGORY CO ^�
tect/
ArchiEngineer Lk.No: J
NELSON QTY ELECTRIC PERMIT FE�EF BUILDING PERMIT INFO
Addmec q q 6 Qt)Ql4T0 LA SN l A[ZI( a,/'JgTF PFRhETISSIJANCE a
LICENSED CONTRACTOR'S DECLARATION
I hereby aHrem that l son hcmwd under provLdons of Chapter9(commmc APPLIANCES.RESIDENIIAL
i.swith oftheguslnensandPro(ceslonsCode,and my ROD /
IlmnschIns to anddied. [� PANELS ww
Lke 1 —3 Contra I
Date — Contractor+C�Ns (�/
ARC Hanes used
as public
GOA.!/IeQ 4 OVERI AMPS
p�p�uu0ZO ]undentand my plans sMRbe used upubllcrecoNs. OVER 1000 FLOOR g/SQ.FT.
k Licensed Profa®lanal SIGNS ELECTRICAL
�6g OWNER-BUILDER DECLARATION SPECIALCIRCNT/M6C
T hereby a .(Seat f am 31.5,Bats.a Contractors Ucense Law city or
following reason.(Section 7 t to Bue c and r imp ved Code:h o city it
O TEMP.METER OR COLE INST.
F, awntywhkh requlresa permit to corutruq alter,lmprove,drmolbh,orrepalr
any.tru mpriertoitshmmce,Worequreestheapplicant(orauchper tta / � ^
POWER DEVICES
31 floe a signed statement that he V licensed pursuant It the tion 7000) of Me {OQ 1i i�
SOSµ Contndmr.Llcerd ..d P,f..WLAw C de).rth theith Section7000) andivi ree N LELECTRIC VALUATION
the basis fo the alleged
d exemption.
Any solation le exempt therefrom and
S° the basis for the alleged exemption. Any t tola civil
c(Section o 70715 by any I O 5 7 O Q^
65
applicanthudredd.11.taubjede the applicant toe civil perulty o(nU mare than SWI F!%711RE5 J L
five hundred dollars he pr. 'I
I cue owner of the property, W LEL rSTORIES TYPE CONSTRUCTION
�m ❑, p party,or my employers with wages r there door
mmpen.tis,7DK will do Business awork,andthe PmfraxiomCode:
de: is,not intended Loffered for
O dale(Sec.apply
to Business owner
of property
Co buildsThe or ImpdoYsthemon Law
�$ does notoessuch tomownerorthrouh hisonemsorlmpmvnthereoryarudch OCC.GROUP RES UMTS
EE
who doea sots arenhlmaelfedorwghMaowne.If,ho employees,provided the bolding or
improvementsaremmintencuecroffend fee ds&.thhowever, llcier iii have
T
Improvement 6eold withlnoneyearo(compldioMthe owner-bulWerw111 have '
t en of proving that he did net build or Improve for purpose of sale.). QTy. PLUMBING PERMIT FEE
L a owner of the property,am exclusively contracting with licensed FLOOD ZONE APN
rat acron to ours a projM(Sec 70/4,Buelnev and Profeabns Code: PERMIT ISSUANCE
The Contractor's Lioenm few dm not apply to an owner of property who ALTER DRARV&VERA•WATER(FA)
builds or Improve thereon,and who contracts, fee so& ptnjeds with a
Tactor(.)license!pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B&P C for this reason
Owner - DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y N
Date RECEIPT N
WORKMAN COMPENSATION DECLARATION
1❑I hereby affirm that I have a certificate of consent to self-Inwre or a FIXTURES'PER TRAP .� SCIiOOL TAX Y N
omiflcate of Workena Camprwon atiinsurance are cedlfte l mpythereof(See. RECEIPT N
38YLLab C.) GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y_ N_
Policy p GAS EA.SYSTEM-0VER 4(EA) RECEIPT N
Co any BUILDING DIVISI NFEES
MCertltled copy is hereby fumldheA. CREASE/INDUSTRL WASTE IN'I'ERCFI"IDR P CK FEE
�Certilied copy 6filed with the city Inspection division.CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PACOMPENSATIONINSURANCE SEWER-SANITARY-SIDRM EA.200FT. R.
Uhi..ess.) need rad be complcied If the permit V(crone hundred dellara(SI0()oify th WATER HEATER W/VENT/ELE Q E EEI certify that In the periormance ofthe work forwhich thio permit la baued,I.hall not employany person In any manner n as to became subject to the WATERSYSTEM/TREATING Workers'Compensation Law.of California.Date PAIDO Z NOTICApplicaENEW RESIDENTIAL PLMB. SQFT. Dat¢
Z O NOTlCE7OAPPLICANt:e orkerakArg s'Comp rest Ion catepro icons oft the
Fshould become subject to the Workers'Compenaatlen provlsloroofthe Labor
C N Code,you most forthwith comply with such provisions orthb permlt ahall be BUILDING
W > deared revoked.
a Me Is Lef
CONSTRUCTION LENDING AGENCY SEISMIC 'E
Thereby afrixf.r t ichthi acomdtructlon lending ag7,Civ. .) perioren ELE C
Z once oRhe work(or which thio pgrmitbbwed(Sec.3097,Civ.C.) T e7 � O
V O Lender',Name La A PL B
LL I— Lendar.Addrese '�' QTY. MECHANICAL PERMIT FEE LT,
O W I certllythat I have read thbappBationand statethat theabovein(vendlen -
IL Is corms.I agree to comply with all city and county ordinances and date laws PERMIT ISSUANCE EE AID:
�. relating to building comtroctien,and herebyauthorizempresentativesofthes Z
: Z city to enter upon the abovementloned property for bdpectlon purpoda. ALTERORADDTDMECH.
(We)agree to rave,indemnify an d keep harmlen the City of Cupertino Date Receipt#
V agaimtltabiBllea,pdgmtenG,co sandexpenenwhkhmayinanywayatt a AIRHANDLINGUNIT1TO10,000 CFM) SUBTOTAL:
age Wt ld City In consequence of the granting of this permit.
po AIR HANDLING UNIT(OVER 10,ODDCFM) CONSTRUCTION TAX
�wi;o- ,ZContractor Da
ppllcant _j - lte/7 / EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfntre building occupant store or handle hazardous HEATING UNIT CFO 100,ODO BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.72,and the Date Recei N
I ealth and Safety Com)ySfdlon 75532(a)7 HEATING UNIT(OVER 100,000 BTI) TO
❑ Yea . SpTul No
Will theappllont ture building occupant vu equipment ordevicn VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit haeardous air conlamioant.a.defined by the Bay Area Air
Quality Management Dbtridt BOILER-COMP OHP OR 100,000 BTU) pq a
4Yes 1 aq /A7
haye read the hazy ou.materials requirements under Chapter 6.95 of BOILER.COMP(OVER 100,000 BN) - iW
the California Health&Safety Code,Seationa 75505,25533 and 25534. 1 MAN
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQA VIaV O ���
mspo ibiilty,to notl the occupant of the requimmente which mu at be mat A 3 9
PH or ua^ce of Certlfkate olOavpanry. C
Owor or authmixad agent Date ISSUED BY:
OFFICE COPY