23930 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Pm en Identification PFRMITNO.
Building Addre1 23930
one:
/ �✓ef man AIZS -36,&7 CITY OF CUPERTINO-BUILDING DIVISION
G°"t/ratto .Name: ,A Lic.No: APPLICATION / PERMIT /
r '� >✓s r/�2� 's 35 BUR.DINC EIECTMCALML BINGMML LAICAL CATEGORY CONTROL#
Architect/Engiruxr. Lie Na
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
BLDC
Address PERMITISSUANCE X001
El C] 11LICENSED CONTRACTOR'S DECLARATION
I hereby afflrmthat l am licensed under provisions of Chapter 9(mmmme- APPLIANCES-RESIDENTIAL QOB DESCRIPTION
Ingwllh5ect1an7000)of Divislon3o(the BuNnenand Proless,lons,Cade,and
ingwit OA7000) ddfect. PANELS
Llcenre Clase ��_Lk.# 03 9'
Data 7 Contractor_ nrOl 201IWOAMPS
ARCHITEe used a LARATION `J OVERIWOAMPS SQ.FT.FLOOR AREA $/SQ.FT.
rt Z Z, a sed Profenrstand my plans shall be used as public records. I
Gfdvl.X Licensed Professional SIGNS ELECTRICAL
�4 OWNEReBUILDER DECLARATION SPECIAL CIRCUIT/MISC
-COMPUTER
Zt, Thereby a((Irmthatlam exempt from the Contractor'sLlcense Lwforlhe
following reason.(Section 76315,Business and Professions Code:Any city or
t'Q ceuntywhlch requlydapemuttomtutruct,alter,improve,demolish,or repair TE P.MECERORPOLEINSf.
q� 3 anystructurepriortolbiseuance,also requires the applicant for such permit to POWER DEVICES
�! file a signed statement I=he e.licensed pursuant to the provisions of the ATE V i
3w� Contractor's Licenselaw(Chapter9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
�0� slon 3 ofthe Business and ProfenlonsCode)orthat hets exempttherefromand `O 'the lasts for the alleged exemption. My violation of Section 76315 by sny OUTLETSSWITCHESFIXTURES
applicant for a permit subjectban applicant to a dvil penalty of not more 1 n /Z75aOD
five hundred della.(SM. NEW RESIDENTIAL ELECTR
SQ.FT. STORIES TYPE CONSTRUCTION
❑Las owner of the property,it he employees with weed as Their sole
7s,
compensation,sBBsinessl do ea Professions
ions Code:Th not Intended
actor or License
Law
D sok(See 7096,Business ow and PMeeerty Code:The Contractors License Taw
5$ and
.h.ddoes such pply work
rk ownerofthroug hi.m who nempoym,providedthryat uch OCC.GROUP RFS UNITS
EE wrprov m.ta am ince,
hlsownemp,however,
ilding or
Improvement are not Intended orofkred for sale.If,howeveq Ihebulldin have
TOTAL:
Improvement boold priwiwithinancrhe did ro build r Improve
ofsahave
tl�,(La.owner
of the phedldnabexcl orrvely—for
.....,purposeofuk.). QTY, PLUMBING PERMIT FEE
LI L as owner o!the property,am exclusively mnt.ding with Ildnsed FLOOD ZONE APN
PERMI7ISSUANCE
contractors to construct the projectEke.7099,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who
Wilda or Improves thereon,and who contracts,for such P(o)ecto with s, ALTER-DRAW&VENT-WATER(EA)
anactd(s)licensed pursuant to the Contraders License Law. FEE SUMMARY
LI I am exempt under Sec B&P C for this mason BACKFLOW PROTECT.DEVICE OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
Owner Date RECEBT O
WORKMAN COMPENSATION DECLARATION FIXTURFZ PER TRAP SCHOOL TAX Y N
01 hereby affirm that I have a certificate of consent to self-insure,or a RECETP1'0
certificate ofWorkers'Cemperualonlnsunnce aracertBd copythareof(Sec.
3E0D,lab,C.) GAS RA.SYSTFM-I WCAOUTL
ETS PARK FEE Y_ N
Policy RECEIPT
#
Gmy tirw GAS EA.SYSTEM-OVER 6(EA) BUILDING DIVISION
N FEES
Codified copy is hereby furnished. GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy e.filed with the city Inspection division.
CERTIFICATE OF EXEMPTION ROM WORKERS' GREASE TRAP PAID
COMPENSATION,INSURANCE gE}ygR.SANRARY-STORM EA 1(IOFf Date Recei t#
(This section need ns,be completed if the permit Is for ars for one hundred doll
(5100)orleee') WATER HEATER W/VENT/FJ.FLTR ENERGY FEE Y_ N_
1 mi tlfy that In the performance of thework forwhlch the.permit Is issued,
I shall ns,employ any person In any manner an as to become subject to the WATER SYSIFM/TREATING
Workerid
Cnpensation Laws of California.Date PAID
-
0 Z ApplNOTICant NEW RESIDENTIAL PLMB. SFT. Date Recei t#
Z O NOuldbe.ICIETO APPLICANT:to
ager makingthis
CompenCertifsation
is Exemption,you
should become subject to the Workers'Campensadon previsions of Leber TOTAL:
9q Code,you==fcart hwlth comply with such provisions or this permit Nail be_ BUILDING=I
deemed reked.
W , voCONSTRUCTION LENDING AGENCY SEISMIC FEE
CL e Iherebyaffirenthatthere kaconstmction lendingageocy Scribe perform- ELECTRIC FEE
M Z ante of the work for which this permit 1,Issued(Sec.3097,Civ.C.) TOTAL
O O Lender'.Name PLUMBING FEE
F Lender'.Address QTY. MECHANICAL PERMIT FEE
LL MECHANICAL FEE
OW comet.
Iareeto e mad comply
ith allcitknanddaty ordinances cinformation d gate laws
1 bmingtobildtg comp(ywlth all countyordinances
representatives
and stat el awe PERMIT ISSUANCE FEES PAID:
} ciytoenterupongmnstuctioryaoned rebyprop rty authorize pedio npurpos o(the.
f., Z dryWenteree to the above-mentioned and Propertyfor kthe Cit purposes. ALTER OR ADD TO MECH. Date Recei t#
(We)agree to save,Indemnify and keep harmiea the in
of Cupertino
/J against liabilities,jtdgment,mrteand expenses which may In anyway acvue AIR HANDLING UNIT OO 10,000 CFM) SUBTOTAL:
agalizid Cl In n endo! antingalhe.pe t.
AIR HANDLING UNIT O,W
(OVER IDCFM) CONSTRUCTION TAX
Igwmreo(App(rant/Contra or Date EXHAUST HOOD(W/DIKT) CONSTRUCTION TAX PAID:
.HA7ARDOUS TERIALSDISC SURE
Will the applicant orfuture building C¢dapant sore or handle hazardous TINGUNIT(10100,0003TU) Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.11,and the
Health and Safety Cade Section25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
Yes No
n
i ..the applicant or tWilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) I599A IrL
DATE
which emit hs arelma zur contaminants as defined by the Bay Area Air
Quality Management District?. BOILER-COMP OHPORIW,000 BTU)
2
❑Yes ❑No JUL 7 199 .
Ihave road the hazardous materials requirement,under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) JL.
the California Health&Safety Code,Sections 25505,25S33 and 25539. I
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. CITY
UJ'CUt-rnt11VVO
responsibility to notify the occupant of the requirementt which rreast be met
pdor t.i.uance a a Cedifi.te.f Occupancy.
Owneroraulhorimd agent Date TOTAL: ISSUED BY;
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Pm en Identification PFRMITNO.
Building Addre1 23930
one:
/ �✓ef man AIZS -36,&7 CITY OF CUPERTINO-BUILDING DIVISION
G°"t/ratto .Name: ,A Lic.No: APPLICATION / PERMIT /
r '� >✓s r/�2� 's 35 BUR.DINC EIECTMCALML BINGMML LAICAL CATEGORY CONTROL#
Architect/Engiruxr. Lie Na
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
BLDC
Address PERMITISSUANCE X001
El C] 11LICENSED CONTRACTOR'S DECLARATION
I hereby afflrmthat l am licensed under provisions of Chapter 9(mmmme- APPLIANCES-RESIDENTIAL QOB DESCRIPTION
Ingwllh5ect1an7000)of Divislon3o(the BuNnenand Proless,lons,Cade,and
ingwit OA7000) ddfect. PANELS
Llcenre Clase ��_Lk.# 03 9'
Data 7 Contractor_ nrOl 201IWOAMPS
ARCHITEe used a LARATION `J OVERIWOAMPS SQ.FT.FLOOR AREA $/SQ.FT.
rt Z Z, a sed Profenrstand my plans shall be used as public records. I
Gfdvl.X Licensed Professional SIGNS ELECTRICAL
�4 OWNEReBUILDER DECLARATION SPECIAL CIRCUIT/MISC
-COMPUTER
Zt, Thereby a((Irmthatlam exempt from the Contractor'sLlcense Lwforlhe
following reason.(Section 76315,Business and Professions Code:Any city or
t'Q ceuntywhlch requlydapemuttomtutruct,alter,improve,demolish,or repair TE P.MECERORPOLEINSf.
q� 3 anystructurepriortolbiseuance,also requires the applicant for such permit to POWER DEVICES
�! file a signed statement I=he e.licensed pursuant to the provisions of the ATE V i
3w� Contractor's Licenselaw(Chapter9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
�0� slon 3 ofthe Business and ProfenlonsCode)orthat hets exempttherefromand `O 'the lasts for the alleged exemption. My violation of Section 76315 by sny OUTLETSSWITCHESFIXTURES
applicant for a permit subjectban applicant to a dvil penalty of not more 1 n /Z75aOD
five hundred della.(SM. NEW RESIDENTIAL ELECTR
SQ.FT. STORIES TYPE CONSTRUCTION
❑Las owner of the property,it he employees with weed as Their sole
7s,
compensation,sBBsinessl do ea Professions
ions Code:Th not Intended
actor or License
Law
D sok(See 7096,Business ow and PMeeerty Code:The Contractors License Taw
5$ and
.h.ddoes such pply work
rk ownerofthroug hi.m who nempoym,providedthryat uch OCC.GROUP RFS UNITS
EE wrprov m.ta am ince,
hlsownemp,however,
ilding or
Improvement are not Intended orofkred for sale.If,howeveq Ihebulldin have
TOTAL:
Improvement boold priwiwithinancrhe did ro build r Improve
ofsahave
tl�,(La.owner
of the phedldnabexcl orrvely—for
.....,purposeofuk.). QTY, PLUMBING PERMIT FEE
LI L as owner o!the property,am exclusively mnt.ding with Ildnsed FLOOD ZONE APN
PERMI7ISSUANCE
contractors to construct the projectEke.7099,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who
Wilda or Improves thereon,and who contracts,for such P(o)ecto with s, ALTER-DRAW&VENT-WATER(EA)
anactd(s)licensed pursuant to the Contraders License Law. FEE SUMMARY
LI I am exempt under Sec B&P C for this mason BACKFLOW PROTECT.DEVICE OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
Owner Date RECEBT O
WORKMAN COMPENSATION DECLARATION FIXTURFZ PER TRAP SCHOOL TAX Y N
01 hereby affirm that I have a certificate of consent to self-insure,or a RECETP1'0
certificate ofWorkers'Cemperualonlnsunnce aracertBd copythareof(Sec.
3E0D,lab,C.) GAS RA.SYSTFM-I WCAOUTL
ETS PARK FEE Y_ N
Policy RECEIPT
#
Gmy tirw GAS EA.SYSTEM-OVER 6(EA) BUILDING DIVISION
N FEES
Codified copy is hereby furnished. GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy e.filed with the city Inspection division.
CERTIFICATE OF EXEMPTION ROM WORKERS' GREASE TRAP PAID
COMPENSATION,INSURANCE gE}ygR.SANRARY-STORM EA 1(IOFf Date Recei t#
(This section need ns,be completed if the permit Is for ars for one hundred doll
(5100)orleee') WATER HEATER W/VENT/FJ.FLTR ENERGY FEE Y_ N_
1 mi tlfy that In the performance of thework forwhlch the.permit Is issued,
I shall ns,employ any person In any manner an as to become subject to the WATER SYSIFM/TREATING
Workerid
Cnpensation Laws of California.Date PAID
-
0 Z ApplNOTICant NEW RESIDENTIAL PLMB. SFT. Date Recei t#
Z O NOuldbe.ICIETO APPLICANT:to
ager makingthis
CompenCertifsation
is Exemption,you
should become subject to the Workers'Campensadon previsions of Leber TOTAL:
9q Code,you==fcart hwlth comply with such provisions or this permit Nail be_ BUILDING=I
deemed reked.
W , voCONSTRUCTION LENDING AGENCY SEISMIC FEE
CL e Iherebyaffirenthatthere kaconstmction lendingageocy Scribe perform- ELECTRIC FEE
M Z ante of the work for which this permit 1,Issued(Sec.3097,Civ.C.) TOTAL
O O Lender'.Name PLUMBING FEE
F Lender'.Address QTY. MECHANICAL PERMIT FEE
LL MECHANICAL FEE
OW comet.
Iareeto e mad comply
ith allcitknanddaty ordinances cinformation d gate laws
1 bmingtobildtg comp(ywlth all countyordinances
representatives
and stat el awe PERMIT ISSUANCE FEES PAID:
} ciytoenterupongmnstuctioryaoned rebyprop rty authorize pedio npurpos o(the.
f., Z dryWenteree to the above-mentioned and Propertyfor kthe Cit purposes. ALTER OR ADD TO MECH. Date Recei t#
(We)agree to save,Indemnify and keep harmiea the in
of Cupertino
/J against liabilities,jtdgment,mrteand expenses which may In anyway acvue AIR HANDLING UNIT OO 10,000 CFM) SUBTOTAL:
agalizid Cl In n endo! antingalhe.pe t.
AIR HANDLING UNIT O,W
(OVER IDCFM) CONSTRUCTION TAX
Igwmreo(App(rant/Contra or Date EXHAUST HOOD(W/DIKT) CONSTRUCTION TAX PAID:
.HA7ARDOUS TERIALSDISC SURE
Will the applicant orfuture building C¢dapant sore or handle hazardous TINGUNIT(10100,0003TU) Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.11,and the
Health and Safety Cade Section25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
Yes No
n
i ..the applicant or tWilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) I599A IrL
DATE
which emit hs arelma zur contaminants as defined by the Bay Area Air
Quality Management District?. BOILER-COMP OHPORIW,000 BTU)
2
❑Yes ❑No JUL 7 199 .
Ihave road the hazardous materials requirement,under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) JL.
the California Health&Safety Code,Sections 25505,25S33 and 25539. I
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. CITY
UJ'CUt-rnt11VVO
responsibility to notify the occupant of the requirementt which rreast be met
pdor t.i.uance a a Cedifi.te.f Occupancy.
Owneroraulhorimd agent Date TOTAL: ISSUED BY;
OFFICE COPY