23735 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prn'ee Identification PERMIT NO.
BMOdmg Address:
w1 �, cD ^ ��• 23735
JwneR/Nl Se TJ�t7i Sz
n m: me: APPLICAlIONSUBMIIIAL A
r%U E Q OT .SZS t,_3 CITY OF CUPERTINO-BUILDING DIVISION
oaco,.Name: m.Nn: APPLICATION /PERMIT
BUILDINGELECTRICAL-PLUMBINC-MECHANICAL CATEGORY CONTROL N
Mchnect/Engfaer. Lb.No:
Vzvl '- - 'r•"' -BUILDING PERMIT INFO .
ELECTRICP,ERMPLUMB Nl�li
IT FEE
Add. PFRMITiSSUANCE 0 0 0
LICENSED CONTR under pnwiscon.
DECLARATION
I hcebcdon7O )o(Di llcmaeduederprovW dPmfeWmar9(oammm APPUANCESRESIDFMIAL JOB DESCRIPTION
Ingwllh5ectbn7000)af Dividan3o(the BualnmandPro(edon.CMr,and my
liana V In hrl]{�and effect �rr777 S-I? PANELS S kk-%,1 M
License CClassLIaN �
Dat` /...' Contractor
a ceOQ �� 0 MI-IWMSC�HDECLARATION
ZIunentaM my pit.ahall
be used precords. OVFRIOAM
PS / ILOFjL.JQp'OORC 5/SQ.Ff.
�j Licensed Prof 1 SIGNSELECTRICAL _
?<LOOuuII OWNER-BUILDER DECLARATION I t f'
77 Ihembya rtnthtiamexemptfromthe Centra eaLlomlawfmthe SIeECIALCB4CU17/MISC .l't' Y `�
following .EeNon 70315,Bu.inm an,Prolmbru Code:My tlty or TENT.MUM OR POLE INST.
nt'E7J oarntywhirh rtgt(Seap 7031AB ur..od1Pru saI. Cod.:A orrtpatr / G
any.Isu nedstamiGib Wu arc e,Umoseubelhant W the
lmaurhpeof to POWERDEVICES
Bit a actors ictmnt that h V Banged pursuant ft the pro 7000) of the
Conersctora Ucerue law(Chpter9(mmmentlng wkh Secclon 7o00)o(Divi- SWIMMING POOL ELECTRIC VALUATION
OS abn3ofUeBuafnmandPMmloru Codd erthat hebessmpt thert(romaM
th Wsb for the allrged eaemplion. My violation cr Section 70)15 by any DUTLETSSWIT'CFffSPTXTURFS ..
LO appBantforaper =b*UtheappBcmttoadvilpemhyofnm==than
M Bred dolWa(f5081. NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPECONSTRUCTION
L as awmr o(lha property,or my employees with wage as their sok
_o< mmpcnxtfon,wBldothework.mdthestrucwrc hrustlntendedor offered for
e F O sale Gee.70K Buaimss and Profosloe Code:The Contractors Uame Lw
don not apply to an owner of property who Wilda or tmprovn themor,and OCC.GROUP RES.UNITS
whodensuchworkhim H.,throughhi....mployeea,p.idedthatauch
ImprovemeNsarc wt Intended oroffered fcesale.IL however,thebulWing ue TOTAL
ImprovemerdbwldwlthlnomyearofcmnpldWmtheowner-buWerwW have _ .,
t1)tturdes of posting that he did not build or Wprove for purposes of sale.). QT'Y;%'�;:, �PLiJMBING PERMIT' . '." FEE"' FLOOD ZONE APN
L j L as owner of the property,am exclusively contacting with 11...d PERMIT ISSUANCE
contaclms to construct the pro)ecl(See 70K Buabm and Professions Code:
The Contractors License Law don net apply tom owner of property who
builds or Improves theme, and who contracts for such plojem with a ALTER-DRAIN 4 VENT-WATER(EA) _ i_ s•,
Licensed pursuant to the Centocor'.License Law.
I am exempt under Sea B It P C for this reason BACK FLOW PROTECT.DEVICE
OwnerDate DRAINS FLOOR ROOF,AREA.CDND. SANITARY RECF N
• WORKMAN COMPENSATION DECLARATION SES PER TRAP SCHOOLTAX Y N
❑I herby affirm that I lave a artlBote of consent to self-boom,or a RECTIPT 0
certificate ofWorkrWCompeealion leuanm or a certified copy thereof(Sec. GAS EA.SYSTEM-I INC-40UILEIS PARK FEE Y N
3800,IabCJ
ry
PoIIN BE,=N
GAS EA.SYSTEMOVER4(FA) BUILDING DIVISION FEES
CmtWed copy is hereby furnished. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certs ied copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE SEWER:SANITARY-STORM F.A.200FT Date Recei til
(Thissectbn need oat h completed Bth pemdt blmora hundred dollen
(51aWce)m.) WATER HEATER W/wEM/ELEcrR ENERGY FEE Y_ N_
I mrWyuat b Ne perfomunce of thewmk forwhich W.pemdt 1.issued.
I.hal]one employ any person In any manner su u to became subject to the
Worker?Comperuadon I..of GWomla.Date WATER SYSTEM/TREATING PAID
I Z Applicant NEW RESIDENTIAL I'IMB. SQFT. Date Reeei til
O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provie..of the Labor TOTAL:
N Cede,you rust forthwith comply with such provisions or this perro t shall be BUILDING FEE
r�
j decreed rooked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
Ibertbyaffirm that then is a mrsorutttrn lending agency for the perform TOTAL: ELECTRIC FEE.
J Oanaeftheworkforwhichthbpermbhisaued(Sec.3097,CIv.CJ
) - LaMedt Name - PLUMBING FEE
F Lendee.Mdnea. QTY. MECFIANICAL PERMIT ' 'FEE MECHANICAL FEE
O 1mdifylhatlhavemdthbapphmtbnaMuatethattheabove Infor tim
0. hocnea.1 agree totomplywith all city and county ordinance and rote law. PERMIT ISSUANCE FEES PAID:
N relating to building construction,an,hereby authorize repressntativet of this
tl to enterupon the above-mentioned fceW ion ALTERORADDTOMECH.
- Z
city
agree o save,Indemnify an d keep harmless theity of�a Ino Date Retel ted
against Liabilities,judgments,mrts and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,ODO CFM) SUBTOTAL:
against said CHs,N con.ryuenm of the gram ing of this permit.
AIRHANDLINC UNIT(OVER lo,ol]o CFM) CONSTRUCTION TAX
7—
Sig.WmofAppBant/Contraem Date EXHAUSTHOOD(W/DUCn CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or town:building occupant store or he and le haeardaus HEATING UNIT(TO 100,000811) Date Revel ted
mrterial as defined by the Cu pertlno Municipal CMe,Chapter 9.12,and the
Hc.hh and Safety CMe Section 25532(.)? HEATWG UNIT(OVER IMOOO BTU) TO
nYe fuw VENTILATION FAN SINGLE RESID) ISSUANCE DATE
BI the applicant or lutN.building occupant sax equlpmenr or device
which emit hmrdous air contaminants as defined by the Bay Arca Air
Quality Management District? B01LER-COMP OHP OR 100,OM BTU)
Y. ❑No
have read the haardousruterlab (OVER requirements under Chapter 6.95 of BOILER-COMP 100,000 BTU) A D
• ' the 6718 nia Health k Safety Code,Sectlons 25505,25533 and 25534.1 kf
u ndmuM that if the building does not amntly have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT
resporabl]ity to notify the occupant of the requirements which must be mil NRY (v 7
prior to issuance of.Certffiateof Occupancy. ` c 199• • '��
Owner or authorised.agent Data Cl�l�r�rz= F`•//
8 TOTAL: ISSUED
OFFICE COPY