23492 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project ldenilaUan PERMIT NO.
BuildingAddress:
- 23492
2l`1oS Go2•'f9 MA 6 w ,
s one:
CITY OF CUPERTINO-BUILDING DIVISION r C_—6�
Ca actorsName: Lk.Na: APPLICATION / PERMIT
-
1 SCC an 1727 BURDINGELECTRICALPLUMBI G- HAMCAL CATEGORY CO
( � rchltc sneer. Lk.No:
G —
QTY ELE ICP IT FEE
BUILDING PERMIT INFO
Aj(P4:o wIiw sze .J. PERMITISSUANCE 31
— Eta
LICENSED CONTRACTOR'S DECLARATION IC
I hereby afflmnthat l am licmaed under provisions of Chapter 9(comment, APPLIANCES ENITAL JOB DE9 RR'D N
ingwlth Se on7000)o(DiAsion3ofthe Buslwsand PmicadonsCode,and my
Hums is In full( and effect. 2 PANELS "
LI¢nse Clj�=LI.N /J 7 ' • I'� �rJeV/ IV / /
Date Contnctar
ARCHITECTS DECLARATION -I ^MP"'
pkp�vu MX I understand my plans shall be used as public retards. 1000 AMPS SQ.FT.FLOOR AREA E'/`�QFT.
}e� Licensed Professional
SIGNS
,SQ
yd.aOWNER-BOLDER DECLARATION
Z p., Thereby a((Imnthatlam exemptfromthe Contractors License Law fm e L
o following reason.(Section 7MI5,Buslnm and Professions Code:My dty or
r21" cmntywhkhrequlresapermlttommtmd,alteplmptove,demolish,orrnpalr TEMP. LE INST. ^�N/
any structure prior to its issuance,also requires the applicant for such permitto pOWFRD CES Lr(R
ryG file a signed statement that he b Ilcenaed pursuant to the provblom of the
, 3p,yl� Contractor's License Law(Chapter 9(mmmencing with Section 7000)o(Divi- GPOOL ELECTRIC ALUATION
X07 slon3ofthe Butln smdProfemlomCode)orthatheisexemptlhemfmmand yrs
65 O•]] the basis for the alleged exemption. Any violation of Section 70315 by any Ol17LETSSWITCHESFIXT•URFS vE V-10.t
appliantfare permit subjMsthe applicant to a civil penalty of no rmrc than
CJ JJ
n� anareaaamrs(Esom.
NEWRESIDENTTALELECTR FT. S[OR]ES TYPE CONSIRlKT10N
I,ae owner o!the properly,or he employees with wages ae ek sole
mm(Sce.7KBuldothawork tinte structureboot intendado f(e r
D role(Ser.7004,Business and Professlem Code:TM Contractors as _
does not apply to an ownerofproperty,who Wlkls or imp est crap and ' � OCC.GROUT' RES.UNITS
whodoromch work himself orthwgh Msownemploynaprovld tha m
improvements are not Intended proffered for sale.If,however,the ulld 1 T
improvementbsoldwithinomyearolcompldlory theowne, Oil rwIII
thq*rden of proving that he did not build or Improve for purpo ofsale RMIT FEE piOpp 7pf� ppN
LJ 4 as owner of the property,am exclusively mntraning wl Ilan .
contractors to construct the pmjecl(Sea 7034,Business and Prate m Code:
The Contracbm.Lima.Law don oat apply to an owner of pro who ALTER-DRAIN&VENT-WATER(EA)
Wada or Impmvn thercory and who contracts!ee such p(o)em wIM a x�a FEE SUMMARY
c
pam(a)licensed pursuant to the ContndMa Lt...Law. t BACK FLOW PR01'ECT.DEVICE �►
I am exempt under Sec B k P C for this reason
FFVQ
DRAINS FLOOR A,ROOF,ARECOND. SANITARY Y N�
(Tuner Date RECEIFT N
A*
WORIONAN COMPENSATION DECLARATION SCHOOL TAX Y N
( 01 hereby aRlrm that I have a mrti(iate of consent to selbinmre,me TIRZES PFR TRNn 1 - RECEIPT N
¢rtifiate of Worken'Compematlanlmunnce ore¢rtl(kd ropy thereof(Sec. CAS EA.SYSTEM-i INCA PARK FEE Y N
3800,Iab C3 —
Policy N RECEET N
Com sy GAS EA.SYSTEM-OVER4(EA) BUILDING Of
ION FEES
Q ertified copy b herebyfurnished.the city GREASE/WDUSTRL WASTE INTERCEPTOR P CHE �� N
Certified copy V hied with the city Inspection division.
CERTIFICATE OF UEMFTION FROM WORKERS' GREASE TRAP P
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.2110FT. Date RCOeI
OD
(Thlemction need oat he completed lithe permit b foram hundred dollars
a100)or less) WATER HUTIIt W/VENT/ELECTR � ENERGYFEE Y
I certify that In the performanceof the week forwhich this permit Is Issued,
I shall not employ any person in any manner n as to be bjM to the WATER SYSTFAf/TRUTING JJJ
Workcn'Conyt>njutl=nldlva o/ Ia.Date_,����$L PAID
0 Z Applicant r yL JC_ NEWRESIDFNIIAL PLMB. SOFT. Date REOEi til
Z O NOTICE TO LIQ CAM:)LaRer ituklng this Certificate of Exemption,you
should become subject to the Wkers*Comprecalon provblom o(the Labor O
I N Cade,you muorst forthwith comply with such provblom orthb permit shall be D
IN
LU j. deemed mocked. .
CONSTRUCTION LENDING AGENCY KCONSTRUCT�IL
VK. IDA
MZ sere oJIUIL
Iha.byf
fflork"fo that whkht becomtructlonlendingd(Sm agency Clo. the perform- 1/ a�a
Z Lender he work(or whkhthb permit bLLmed(Sec 3097,Civ.C.) 16f el
V O I<nder'shame
LL F- Lenders Address QTY. MECHANICAL PERMIT FEE EE
0 W I certitythat I have readthh application and statethattheabova Information
1 bcorrect.l agree tocomply with all city and county on1immesand state laws PERMIT ISSUANCE
relating to building construction,and hereby authorize representetive,o(thb
I— N city to enter upon the abo cmmntiamd property fm Impaction purpoen. ALTER OR ADD7O MECH.
? (We)agree to save,Ind enmity an d keep harmless the City of Cupertino Reeei t0
V agaimt liabilities,ydgnouts,cons and expenses which may In any way acme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL-
.g.1 Id City consequence the gaming of this permit AIR HANDLING UNIT(OVER 10,000C M- TAX
/v 2 /5 CONSTRUCTIO TAX PAID:
n mreo Appllant/Contractee Date EXHAUST HOOD
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UMT(TO 100,0001ITU) Date CCC] til
materialaedeflnedbythe Cu Municipal Code,Chapter 9.12,and the
health and Safety Code n25532(a)7 }LUTING UNIT(OVER 100,000 BTN 'I'A
C3 Yrs L7rN.
Will the appll or taro building occupant use equipment or devices VENTILATION FAN(SINCLE RESID) ISSUANCE ATE
which emit haranlous air contamiwnts as defined by the Bay Area Air
(N lily Management Dbtrid BORER-CAMP OHP OR 100,0(10 BTI)
Yes o N�N
California
lheh
Mous Seatiou(rerrcntaundeand 25534 6.95 of BORER-COMP(OVER1 D,XDBN) A
the
erstan that
th A9afety Code,nectiore2tly have a trean75534.1
understand that notify
the occupant
oft therequirements
haven hick tlatb is my NEW RESIDENTTAL MECH. SQ.IT.
priori
responsibility to nditytheompantoftherequirnmenb which must be and OCT 22 19
' pdort ssuanc fa Cedlfi to o(Occupanry.
ah-34
Owner or aulhorlmd agent Dae ISSUEDB
OFFICE COPY