20036APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Proem Wentlfkatlon
Building Address
23Soo Cfzzs-to E)R Vu 2111 T
PERMIT NO.
2
003V/
ansa: �� auSubmit
r'(- L�Ar {J(71—�'3
CITY OF CUPERTiNO-6UILDING DIVISION
APPLICATION/PERMIT
BUnXiNGELE)CTRIC PLUMBINGMECIIAMCAL
®A
Contrstlm'.Nama, Ix. N.
CATEGORY
CONTROL,/
Amhlea}/En r.
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Add— (D 6 l S `QL�
"rvmr IT
❑ j�l, ❑ ❑
��(j
y�
PERMITISSUANCE �W
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that lam hcemed under p.W.,of Chapter 9 (oxnmm
ingwlthSecibn7000)of Dividm3ofthe Buslmasand Profession.Code, and my
li¢rae la In full form and affect
D.t Ch. mu
Date Contncor
ARCHITECT'S DECLARATION
I uclemtard my plans,hall be used as public menrdL
Llocnecd Pmfealorul
OWNER -BUILDER DECLARATION
Iherebyaffirmthat1amuemptfromthe Comr ori Llunne Lawforthe
folbwbhg rtaeon. Section 7115, Buninea and Profeabm Code: Mytlty or
countywMchrequL apemdttowWmd,altm,lmpmve,demolbh,orrepair
anyumclureprlmtoibla me,aborequimtheappBantfmsuNper to
file a Ngeed dam ent that he b licensed pntursuato the proVbbru d the
Contractor',)Xenae Law (Chaper9(comencecingwhh Section 7000) of DM-
,ion 3 of the Bu Wm and Pmfmbru Code) orthu he b mmpt themfmmard
the Wits for the alleged exemption. Any violation of Solon 7[015 by any
applant for a permd subjecs the applicant to a ctadl penalty d not mon than
live hundred dahm($ .
❑ I, as owner of the property, or my employee with wages as their axle
compemaban, will dothe work, and thestm�re b not Intended or offered for
sale lSee 701 , Busies, and Prd®bra Cock The Cmumdoe. Llama Law
don out apply to N owrur d property who builds or improve thenen,and
who dm such work himself mthrough his own employees, provlded that such
Impmvemenbartnot Intended oroffered fee Y. If, however, the Wilding or
Improvementbsd hlnomyearofcompletbn,thewvner-builderwihave
t rdenof Imenl.gthat hedld notwnd.,improve forp�rpseofaale.).
LJ L u owner of the property, am e.<hrslvety eantraeting with limmd
¢ntract¢s to ronstruct the project (St. 7Dtq B ineaand Profeabm Code:
The Cordnctor'a Lkena Law doe not apply to an owner of property who
bol
Wilds or impmve thereon, and who, roErsc, for such ptujecta with a
Tdor(s) Bteaed pursuant to the Contractor's Ll¢e, nlaw.
p uMer am ..emSec B k P C for this recon
APPIRANCESRESIDENTIAL
JOB XSCREFTION
L—�'(�I, 1- U L—r,—X
PL
PANELS
UP TO 200 ANIPS
101-1000 AMPS
OVER 1000 AMPS
SQ. FT. FLOOR AREA
IN
P
7
8/SQ. Er.
A
SIGNSELECCRICA1, fINALED
SPECIAL CIRCUIT/MISC
3-010
TEMP. METER ORPOLE INST.
-
POWER DEVICES RII�TE
DA
DATE.
SWAIhINGIWLELECTRIC
VALUATION
OITILEfSSWITCHESFIXTURFS
NEW RESIDWIiAL ELECTR SQF7'
BIOMES
TYPECONSIRL'CTION
,
TOTAL
QTY. PLUMBING PERMIT FEE
OCC.GROUP
.
RES. UNRS -
PERMIT IsELIANCE
ALTER-DRAW A VEM -WATER (EA)
FLOOD ZONE
APN
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
S FLOOR DRAINFLOOROAREA, COND.
SANITARY Y N
REC=s
Owner Due
WORKMAN COMPENSATION DECLARATION
F11 hereby affirm rust I have . certificate d ..t to pythuurt, ¢ a
m aofWorken'CompenuuonImuran¢or•¢tilled copythareof Sec.
3800,labbCJ
I� I
FID(TURES PER TRAP
SCHOOL TAX Y_ N_
RFGmRs
GAS EA. SYSIFAt-1 WG40I71LEI5
PARK FEE Y_ N_
I
GAS EA. SYSTEM -0 A) VER / (E
C y
BUILDDINGING DIVISION
DI V ISION FEES
Cenifid copy b hereby fundshed.
Certs ied copy b filed Mth tha edy Impeetbn division.
CERTIFICATE OF EXiMPTION FROM WORKERS
COMPENSATION INSURANCE
URA
OTIC ae¢bn mM oat be Completed tIr SURA
b f¢om hundred dollars
fS1I nifyth) thew¢k so as to thbpermRlsbooed,
I¢nor thatlnthe person
I shag not employ any peaon rf any manner at u to become subject to the
W Compensation Iuvn o GB1mn
/b. Due
NOTIpliCE
NOTICE To ..bjAM:I, after making Certlflute of Exemption, you
shshouldbroome, subjeect to the Workers' Compematlan provLbns of the Tabor
Cade, yea =at fon hwhh omply with such provisions or this permit shall be
deemed revoked.
CONSTRICTION LENDING AGENCY
Ihembyaffirm that then Is a constmclon ledingagency forth,perform,
¢
anof the work for which this permit is Wue i Spee 30Y/, CIv. C)
lends/,Name
Iendar.Acidms
Ieenlfythul havemadthhappB tbnad Matethatthea nuvmmHion
bmr .Idgmtocomplyw auckyadmuntyordwnoy ditelam
relating to W I lding construction, and hereby authmira repmentatioes of this
city to enter upon the above-mentbmd property fm lnspMbn purpoaes
(We) agm to amee, indemnify an d keep harden the City of Cupertino
agabut liabWtie,,judgments, ooesand e.pensewMeh mayor anywayamue
agalmt said City in consapunae of the granting d tids permit.
GREASE/INDUSIRL WASTE INI'FRCf1rMR
PLANCHECK FEE
PAID
- - Date Remi t#
GREASE TRAP
SEWER-SANTIARY-STORM EA �T
WATER HEATERW/VEM/EECTR
ENERGY FEE Y N
PAID
Date _'Receipt -
WATER SYS[EM/TREATING
NEWRESIDENTIALP[MB. SQFT.
TOTAL:
SEISMIC FEE
TOTAL:
ELECTRIC FEE
L O
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
ALTFRORADDTOMECH,
Date ReM t#
AIR HANDLING UNIT(TO 10,000CFSI)
SUBTOTAL•
AIRHANDLING UNIT (OVER 10,"CFM)
CONSTRUCTION TAX
S1gmEm of Appl¢nt/Contract¢ Dat.
HAZARDOUS MATERIALS DISCLOSURE
Wll the applicant orfutom building occupant store or handle havrdom
material a, defined by the Cupertino Municipal Code, Chapter 9.11, and the
Eleahh and Safety Code Section 2SSM(a)7
❑ Yen No
Will theapplaEm tun Wilding occupant use equipment or devlms
which emit luvrdaus air rmnadmnts as defined by the Bay Area Air
Quality Management District?
4 Yes No
the California l leahhety Codec read the ba7arows , Sectbm S505als b23533a d25under p531695 of
understand that lithe Wlding don not currently have a tenant, that It b my
resprmbility to notify the occupant of the requirements wh_kh most be met
prior us.. ,.. da Ccnikate &0.ry��nn �'j
In
E)(HAUSTHOODDV/DUC'D
CONSTRUCTION TAX PAID:
HEATING UNIT OO 100,000 BTU)
Date Recent#-
HEATING UNIT(OVER II,OOD BTU)
TOTAL:
O O
VENTILATION FAIN (SINGLE RESID)
ISSILANCE DATE
TT
�L
PR � 5 I99r,
APRJ lJ
city
city �r11nP,
ISSUED BY:y IiA./ALJIhaIJ-�+1.
BOILER -COMP OM' OR 100,0(9 BTT!)
BOILfR-NMP(OVER 100,000 BTU)
NEW RESIDFNGAL MECH. SQ.FT
Ownercrauthnnmdagent Date
TOTAL
OFFICE COPY