23179 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro en Identification PERNT NO.
BuBdmg Addmso: 23179
IDBS'
nar ��'''! one:
rg",w /LJ�G9 CITY OF CUPERTINO-BUILDINGDIVISION l-- l'31-9
2
Con adarsNeme: Na: APPLICATION / PERMIT T'
G BUILDINGFlFLTRIG4PLUMBINGMFSHAMCAL CATEGORYArc /Engl r. �Ic.No:
yam/ Q ELECTRIC PERMIT FEE BUILD—INN.,G PERMIT INFO
M IS
Addrca 9 J / PERMITISSUANCE �Vo X �y X
BLUaa
LICENSED NTRA OR'S RATION Y�
]hereby af(Irmthal lam Uceneedu erp ons o(Chapter9(rommec- APPLIANCES-RESIDENTIAL _ —_roypEv�RR1EfON.�
Ingwilh5edion7000)of DiNsion3ofthe Bull and ProfeWons Code,andmy
license Is in fullforce and effed. PANELS
De
teve Clam Contr
Dale Conhador
ARCHITECT'S DECLARATION Ipl-
q�q�vu reO Zp I understand my plass shall be used as public remrdo. OV SQ.FT.FLOOR AREA 5/SQ.FT.
It 0�j Lkeneed ProfessionalSIG $LRCIRICAL T -2z-I— V
Q OWNER-BUILDER DECLARATION SPEC LCIRCUIT/h115C (�.� e
Z � owing eanrrnthalon731.5,BI.ea.mlt usiness
he sad ProdoraLlmnse Lw fort he ^se
o Q
county
eqs.hest permit to Business]herr] feploN Code:Mydtyor pAas�v-�
rountywhkh requlmapermltromsstruct,ilter,Improve,demolish,arrepair _ �p'��S'R]'OLE INSiS 1 7 .
S� < acystmeture pdorto its Lasuance,alsorequinuthe applicentlor such permit to POWER DEVICES se
U file a signed statement that he Is licensed pursuant to the provision,of the
3w Cantradars Licen,elaw(Chapter9(mmmencingwlth Sedlon7000)Of Divi- SWIMMING POOL ELECTRIC . VALUATION
O J thesiobasis fo the alleged
dPro prion. n4,)violation
of exempt therefromaM 1 O n,
6•] the bean for the alleged exemption. My t to1a1Wn of Stolon no
re any O(IILETSSW77CF{FSF7X'I'URES
applicant for a permit subjects the applicant to a civil penalty dna moretlun
fiundreddolWn($500). NEW RESIDENTIAL ELITTR SQJ-7. STOFIES TYPE CONSTRUCTION
�n 6I,as owner of the property,or my employees with wages as Ihelr sole
mmpeneatlon,will do the work and t1u trudure is not Intended or offered for
Osale(Sec.7064,Business and Professions Code:The Contractor's Llmsse Law
$ time not apply to an owner of property who builds or improve thereon,and OCC.GROUP RFS.UNITS
EE who doe such work himselforthrough hisown employee,provided that such ���
Improvements are not Intended oroffered for sale.I(however,the building or TOTAL:
Improvement Is sold within one yearo(completion,the owner-buuderwlll have
t1d,,kurden of proving that he did not build or Improve for purpose or sale.). QTY,I PLUMBING PERMIT FEE
IJ HOOD TINE APN
L ne owner tr the property,am exclusively Business
and
Is Cade: PERMITISSUANCE
mnredore to construct the Law
(Sec.appy to nese end ]pro on,Code: SQQ
The Contractor'.improves,
License Lw does not apply to an owner of property wise
hoods or Improve thereon, and who mated. for such p(ojem with a ALTER-DRAIN&VENT-WATER(EA)
cgtB(ador(q empt under
Scctrothe ContradoYa Limnss Law. . FEE SUMMARY
LJI am exemp under Sec B 4 P C for this recon BACKFLOW PROTECT.DEVICE OUTSIDEFEES
DRAINS FLOOR ROOF,AREA,GOND: SANITARY Y N _
Owner Date VIM❑ EEC__ N N
WORKMAN COMPENSATION DECLARATION FIX7VRF3 PER 7TRAP3C- SCHOOL TAX Y_I hereby a(llrm that I have•oertlliote o!consent to eel!-insure,or a R5=:: p
certificate OfWorkera Compevatlanlvurance me cadifled mpythemof(Sec. GAS RA.SYSTEM- RKFEE Y_ N_
38001I.ab C.) 3-
1INCAOUTLETS PA
RFLEI T p
Polley p rAS F.A.SYSTEM-OVER 4(EA)
Cam any BUILDING DIVISION FEES ��
�Certmed copy b herebyth the city CREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified ropy V filed with the tlty Inspection dlWiloe. at
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASETRAP PAID _
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 2(IOFf Date Recti
(rhlssedlon need not be completed Bthe perrnt laforonehundred dollar
p;
(5100)orlyth WATER HEATER W/VENT/FLF-CTR ENERGY FEE Y_ N
I ll am employ
o the person
any ework for s t oh co penult Is booed,
I ohau ort employ any person lo any sennet ta as to became subject to the WATER SYSITM/TREATING h�6
Waplican Compennatlon Lawa o(Calltornfa. Date 31 aV PAID
Z Z -Applicant NEW RESIDENTIAL PLMB. SQFT. Date Remi t#
O NOTTCETOesubjet to
orkensfter lCompeasationing this pro ofExemption,oftle Labor TOTAL:
N Code,you=at forthwith comply with such provisions orlhb permit shall be BUILDING FEE
W j deemed maked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
IL Z Iherebyatnrm that them b a construction lending agency for the pedorm- TOTAL: a ELECTRIC FEE 3s
7 anmo(theworkforwhichthispermit9lssued(Sec3097,CW.C.) p0
02 Ientido Name PLUMBING FEE %
LL H Lender'aAddrca QTY. . MECHANICAL PERMIT FEE MECHANICAL FEE .00
W
ityve I mdthatl haread thisappucatroove n and stafelhattheabInformation
r
1 Lmrred.lagreetoeomplywithaUcnyandmunty ordinances and gate laws 1 PERMUISSUANCE �' •� FEES PAID: ����o,
relating tob.ilding.vtvdlon,.nd hemby authori"mpmwntatlws of thIs
H (A city to enter upon the abavomendoned property for inspection purposes. ALTER OR ADD TO MECH. 1, 04
? (We)agree to save,Indemnify an d keep harmless the City of Cu pedlno Date Receipt#
V aga Inst liabllllks,judgments,cones nd expenses which may In any way accrue AIR HANDLING UNIT(rO 10,000 GEM) SUBTOTAL'
aga lost said City In mneequence of the gra sling of this permit.
y�� ��Z� ,Aje AIR HANDLING U1,117(OVER 1p,000CFbn CONSTRUCTION TAX
44CSignatureofApplicant/Contractor Dat FXHAUSr HOOD(W/DUGT) L S CONSTRUC'riON TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stare or he ad le harardous HEATING UNIT(TO 100,000 BTU) Date ReCei [#
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the
Hethh and SafetyCade Section25532(a)? HEATING[IMT(OVER lO0,000 BTU] TOTAL:
❑yes r]No
Will the applicant orfuture building ocmpant meequipment or device ' VENTILATION FAN(SINGLE RESID) ,S ISSUANCE DATE
which coat harznlous air contamivntsas defined by the Bay Area Air PAID
Quality Management District? BOILER-COMP DHPOR 100,000 BTI)) P F''LL
71 Yesnn No
TMvemadiheb.9usmaledabrequimmenbunderChapter6.95of SOILER-COMP(OVER 100,000 BTU) JAN 30 1992
the Califomia Health&Safety Code,Sections 25505,25533 and 25534.1
understand that if the building does not currently have a tenant,that It is my NEW RM- DENTIAL MECTL SQFf
responsibility to notify the occupant of the mqW cmrcats which must be mel ^y
prior to Issuance of a Certificate (o
of Occupancy. ny ur curr tI.GNU
Owner or authorlmd agent Date - QTOTAL: ISSUEDBY:"'
OFFICE COPY