23620 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identlnotlan PERMIT NO.
Building Address: 23620
.
2-137D000 s �SZS
wnere one.
JA CITY OF CUPERTINO-BUILDING DIVISION S--N y iX
Contract.e.N me: ( Lic.No:. APPLICATION /PERMIT L-t L�
Am ! L p BUILDING-ELMTRICAI MUMBING-MECHAMCAL CATEGORY CONTROL N
rchftedt/Eingireen LIc.No:
QTY ELECTRIC PERMIT a, FEE BUILDING PERMIT INF�O,�p.
Address I 3 C PERMITISSUANCE X I.
LICENSED CONTRA OR'S DECIARATIO qm
Iherebyafflrentleal l am licensed under provisions of Chapteril(rromenc- AI'PI]ANCESRESIDENML JOB DF�C�Q'l}QN
Ingwlth Sect1on700p)af Dlvltlon3o(the BuslnnaandlerofeWonsCode,and m �
an la in fu fora and d - `I PANELS A (� pKrv-
Llcense�LloN .�47 96 r I. .'I AI _
Date Contractor M .
ARCHITECTS DECLARATION 207-1000AM !'
00 lundereland mypla.ahalbeusednpubhcreo da OVER 1lX0 1 FT.FLOOR AREA S/SQ.Fr.
pQ O
E Iy(C� Licensed Professional SIGNS ELEC AL. _ _ 6 �Za
�dddd6ku OWNER-BUILDER DECLARATION SPECIALC@C / "t ,, t' I' 26� t
�j Gia (here affirm that lamexem from the Contractor's Llcenae Law forth, 1
'Z s�o:3 following reason.(Section 7m1.5,Business and Professions Code:Any city or (j ,.e,�.6D
0Zi"' countywhich requires a permit tamrutruct,alter,improve,demolfsh,orrcpair TIME. O Sr.
Q any structure prbrta lb Wuance,aLsorequlreathe appBnnl(w auchperomtto POWER DEVICES p O 1
G O file a signed&atement that M le licensed pursuant to the provisions of the y l `
3w Contractor's License Law(Chapter9(mmmencingwith Section 7000)of DM.
SOS elon3olthe Buslnessand PnNmAIans Ccde)orthat hai axemmVALUATIONpttherefroand SWIMMING POOL ELECTRIC �-k—
applicant
(`
6 the bean for the alleged exemption. Any applicantto
of penalty of
7031.5 by he UTLETSSWITCHE FIXTURES ss1 Z �L S Q
a he basis for apermit llegedsubjects exemption.
Anyvioation of
nal morethan !/
five hundred dollam($500). NEW RESIDENTIAL ELECTR
�a ❑I,as owner of the property,or my employees with wages as their sole —�'�' SfORIFS TYPE CONSTRUCTION
compensation,will do the work and the structure b not Intended or offered for
O .1.ISM 7014,Biadmosand Pmfessions Cade:The Contndore Llanolaw
$ don not apply to an owner of property who build,or lmprovealhereon,and .00C.GROUP RFS.UNITS
who does such work hlmaelf ortheough hisawn employees,provided that such
improvements are not Intended oroffercd for sale.If,however,the building or TO
Improvement is sold within oneyearofcomplelion,the owmr-bullderwill have
,burden of pmving that he did out build or improve for purpose of salaJ. QTY, rLUftNG PERMIT FEE
II Las owner of the property,am exclusively mntnding with Hameed FLOOD ZONE APN
TIA,Cotmtoconstrudelawdoe(Seo 7 pplytalnessand of prop rtCode: ANCE .r
Wil s or Impr'e License n, does not apply to an owner of property who ALTER-D"-WATERWilde or Imprve Neeson,and who mnmacb !w such pt,ojew wltM1 aFEE SUMMARY
oqp�(+ctor(sexem t underpursuantSec to the Contndor's License Law. BALJ I am exempt under Seo B&P C for thio reasonDRAINSs� SANITARY Y NOwner Date RHCEIT pWORK MAN COMPENSATION DECLARATION ' FIXTURE // SCHOOL TAX Y_ N_
I hereby affirm that 1 have a artiMate of consent to Bell-Insure,w a
RECEIPT N
Into ofWoken'Compenaadonlnsunnawaartlfkd capythenro((Sec. GAS EA.SYSTEM-1 40[IILh-IS PARK FEE Y N
3800,Lab CJI p e1 DING DIV]
CN
Policy If �( ` GAS FA.SYSTEM-0VER6
Com ani Un BUILDING DI VISION FEES
Certified copy hereby lumlehed. CREASE/WDU57RL WASTE INTERCEPTOR PLANCHECK FEE
Certified ropy b filed with IM city Inspection division. 4
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAI J
COMPENSATION INSURANCE SEVER-SANITARY-SIORM EA 200Ff t R f#
Qhlssmlon need net be completed If the permit is forms hundred dollam
(f100)orlemJ WATER HEATER W/VENT/ELECTR ENERGY FEE Y r
Icertifythal In the performance ofthe work for which this permit is issued, V
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Worked Compenntioo Lam of California. Date PAID
O Z ApplicantwNEW RESIDENTIAL PLMB. SQFr. Date RCC, t#
Z O NOTICETO APPLICANT:ILafter making this Cedlflote of Eaemptlan,you
ehld become subject to the Workers'Compensm
at ion pvislons of the Labor TOT
V) Code,you mu at fort hwlth comply with such provlsloes or this permit shall be BUILDING
W ] deemed revoked,
a f] CONSTRUCTION LENDING AGENCY SEISE ,01
Ihembyaf0rmthat there is a construction lendlogagency forthe perform- T E 1 FEE
Z arse of the workforwhkhthls permit biassed(Bee.3097,Civ.CJ
V 2 Lander'-Name G
LL 1- Lender's Add. QTY. MECHANICAL PERMIT FEE HA 1 L E
O W Icedlfy thatl have read thisapplintlonand statethatthe above information ��
ft, is comad.lagreeto complywlth all cityand countyondmanas and nate laws PERMIT ISSUANCE FEM I
} releting lobul7ding construction,and hereby authorize reprexntalives afthis
N cityto enterupon the aWo AmnticmM a forW inspection purposes. ALTERORADDTOMECH.
� Z (We)AS.to save,indemnify an d keep property
the City f ped Ino a Recei t#
.8.1rliabilitles,judgments,mrte 4,14expereas which nay In nywayacvue AIR HANDLING UNIT(TO 10,000CFM) $ TOTAL-
age said City inns ens granting at thm penin . CONSTRUCTIO TAX
AIR HANDLING UNIT(OVER 10,000CFM)
g Wre of Applianl/ConlndorDa E7(HAUST HOOD(V/DUCT) CONSTRUCTIO TAX PAID:
HAZAR DOUS MATERIALS DISCL SURE
Will the applicant or future building occupant store or hand to azardcus HEATING UNIT(TO 100,ODO BTU) Date xzmcipt# as
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Ilea lth and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,010 BTU - O
j�Yee No
TV ill the applicant a�ture building occupant use equlpnrnl w devise VENTILATION FAN ISWGLE RES[D) ISSUAN DATE
which emit hazardous air contaminants as defined by the Bay Area Air f
Quality Management District? BOILER-COMP OHPOR lK000 BTU)
❑ Yrs FF-1�No
l have read the hazardous materials mquiremenb under Chapter 6.95 of BOILER-COMP(OVER 100,00 BIM
the California Health&Sit fety Code,Sed ions 25505,25533 and 25534.I MAY 27 1992
understand that if the building does not comently have a tenant,that it b EST my NEW RDENTIAL MECH. SQ.Fr.
responsibility to AN ify the occupant of the requirements which twat be met ��/�)
prior to Issuance of a Certificate of Occupa racy. CIT YTUf GG Uf�CfTl h\ /Y
Owner or authorized agent Date' ISSUEDBY: VIJI __
ro
OFFICE COPY