23059 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: 23059 '
o ��E�
s £. C.:O/Xo. 9N-98.39 CITY OF CUPERTINO-BUILDING DIVISION
to a�1N (L�cgNo: r� APPLICATION / PERMIT
-.ws' Oa BUIL.DINGELECnUCALPLUMBINGMECHAMCAL CATEGORY - CONTROL a
�i Ash act/ v Lie.No:
BUILDING PERMIT INFO
MP QTY ELECTRICPERMIT FEE
PFRMITISSUANCE �� ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l ace licensed under provWonsofChapter 9(commersto APPLIANCES-RESIDENTIAL L OB DESCKIPITON
Ingwith Sedion7000)of Divldon3 ofthe Busimmand PmfeasionsCode,and my
license la In(WtlfO and effect V, PANELS
Lken es3eetla Lie N O!
DateContractor te, UP TO 2DOAMPS
ARCHITECT°DECLARAIrioN 2014000 AMPS
ceO Zp I understand my plans shall be used u public record• OVER100DAMP5 SQ.FT.FLOOR AREA $/SQ.Fr.
ly LlmneedPrefeubvl SIGNS ELECTRICAL A L E D IN
6 OWNER-BUILDER DECLARATION
z y p SPECIAL C RCU T/M SC
forlhe P T E R
Ihercb alFlrmtlutlam sateen (menthe Contractor's License Law
qq following reason.(Section 70315,Business and professions Code:Any city or -
Fq county which requirs permit toconsleuct,alter,improve,demolish,orrepalr 7E)dP.ME[ERORI'OLE INST. �♦
qE 3 aeystructure prlortolb issuance,alaorequireatheapplicantfor such permit to POWER DEVICES YATE
t5 file a signed statement that he Is licensed pursuant to the provisions of the
6Q3µ,II-- Contractors License Law(Chapter 9(commencing with Section 7DOO of Diet. SWIMMING POOL ELECTRIC
H�OJ don 3olthe Business and Professions Code)orthtihem
et he exempfmmVALUATIONand Sow
the basis for the alleged exemption. Any violation of Section 70115 by any
appBesotfor a permit subjects thespplikert to a dAl penalty of nut more than Un-ETSSWITCHESEX[URFS
five undred dollars($500). SQ,FT. STORIES TYPE CONSTRUCTION
�undred dolars($property, NEW RESIDENTIAL ELECT°
�n p party,or my employees with wages r thele snle
compensation,will troche work and the ions Code: Is net Mended or offered for
O sale(Sec.7064,Bwlvu and Professions Code:The Contraaota License Law
3$ does not apply to an owner of property who builds or Improves threaten,and OCC.GROUP RES.UNITS
who dorosuch work himself orthraugh his awn employees,provided that such
Improvements are not Intended or offered for sale.If,however,the building or T07
Improvement Is sold within oneyearofcompletlon,the oweenbuilderwill have
t1Ekuroving that he did net build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE
u I,Nen of pas owner of the property,am exclusively contracting with licensed FLOOD ZONE APNPERMIT ISSUANCEcontractors to covtto the project(See.7016,Businma al Professions Code:
The Contractor's License Law does not apply to an owner of property who
builds or Improves thereon, and who contracts for such p(ojects with a ALTER-DRAIN k VENT-WATER(EA)
es pypactor(O Bernxd pursuant to the Contrecto's License Law. FEE SUMMARY
lJ I am exempt under Sec. B h P C for this reawn BACK FLOW PROTECT.DEVICE
Owner Date DRAINS FLOOR ROOF,AREA,GONG. SANITARY Y_ N_
RECEITT N
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y_ N_
❑I hereby affirm that Ihive a ceell/iafe of cmxnt to If-Inure,or miulrr tl
cesli0oteofWorkers'Compensatlon Insurance me unified copy thereof(Sec. GAS F.A.SYSTEM-I WCAOUTLE1'S PARK FEE Y_ N_
3800,1.6CJ RECEIPT#
Policypppaaa# GAS EA.SYSTEM-OVER 4(EA)
Comoasty • BUILDING DIVISION BES
C_ fled copy isherebytumecity
ertlfied copy b filed with the city Inspection divldon. CREASE/INDUSTRL WASTE EPTOR PLANCHECK FEE
CERTIFICATE OF.EXEMPTION FROM WORKERS' GREASETRAP PAI
COMPENSATION INSURANCE SEWER-SANITARY- RM EA 200FT P...pt#
(rhlsxdion need not becompleted lithe pemdt b forov hundred dollam
($100)orless.l WATER 7{EATER /VENT/ELECT° ENE E Y N_
I certify that lo the performance of thewmk forwhirh this permit le Issued,
I dull not employ any person in any manner so as to became subject to the WATER SY /TREATING
Workera Compensation Laws of California.Date PAI
ZZ Applicant NEW° ENTIAL P[MB. SQ}T. DB Recei t#
O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should benne subject to the Worken'Compensatlon provislons of the Labor (�NlvTOTAL-
0; Code,you must forthwith comply with such pr iims or this permitehall be BN IG FEE
W > deemed rcvoked.CONSTRUCTION LENDING AGENCY SE IC FEE I0
a Ihercbyaffirm that there Is a construction lending agency sort he perform- TOTAL: 1: ECTRICFEE
Z an,ufthe work forwhich this permit is Issued 5m 3D97,Civ.C.I
V O Leader.Nene PLUMBING FEE
LL I— Lender.Address QTY. MECHANICAL PERMIT FEE MECHANICAL
O W Imrtifythat l have read this appBoNonand statethatthe above Information
is correct.l agree to comply with all cityand muntyordlnances and pate laws t, PERMrrmiLANCE ss� FEES PAID:
} relating lobullding construction,and hereby authorise representatives of this
I.., Z city to enter upon the above-mentioned property for Inspection purposes. LTEROR ADD 7O MFLH. 's Date ace) t#
(We)agree to save,Indemnify an d keep harmieu the City.(Cupertino
V thabluties ydg te,cosit cal xpenxe whichmuyinarywayasetue AIRHANDENC UNIT(x010,000 CFM) SU TOTAL:
gain Id s encs of anung of this permit CONSTRUCTION AX
.ter J p AIR HANDLING IIM7'(OVER 10,000 CFM7
slgnatureo(Appl1' nt ontnctor EXHAUST HOOD(W/DUCT) CONSTRUCTION AX PAID:
HATARDOUS MATERIALS UISCLOSUR
Will theappliantterfuture buildingo.p..t stutter handle harardous HEATING UNIT(TO 100,000 BM Date ecel #
material ae detivd by the Cuyertlno Municipal Code,Chapter 9.12,and the
Health and Safety Code n25532()7 HEATING UNIT(OVER 100,000 BDA T ;
❑ Yro No
Wliltheapplicanl or uNre building oavpant use equipment or devices VENTILATION FAN(SINGLE RE5I13) ISSUANCE DATE
which emit hazardous air tambuntsasdefirmdbythe Bay Area Ab -
1N Ilty Management Dbl ct7 BOILER-COMPOHPOR100,IXDBTU)
❑Ycs No
I have read the M1a>a QuenuterlaLrequlremenbunderChapter G95of BOILER-COMP(OVER 100,000 BTU) LR
the Califwals Health A SafetyCode,Sections 25505,25S33and 75534.1
u co
n dthat if the bu gdteesnatrmatlyhavea lenant,thatitbery NEW RESIDENTIAL MECH SQ.FT ® N
ponsib a pant•tmxments which most be mat
F/5
d to a if eo( Empanel
J q Q7
Owner or authortred agent Date ' )SS(TSD5
ro
OFFICE COPY 1y