23743APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Proea identification
Build ing Add rev:
Tk-Lz- �oruP,: 23 Soo Cr;ssb �e - Pt P+ 306
PERMIT NO.
3 7 4 3
R;ch 4 4^� { l O vj er q t 0.0(.I t7
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION/ PERMIT
BUfLDINGELECTRICALPLUMBING-MECHANICAL
A
Z
co"'
KE Na =' L u—=f•N
VL DT • 1 1
CATEWRY
CONTROL N
rchtect/Engineer. Lie. Na
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address: -
❑ a�a, ❑ ❑
IKAI
PERMITISSUANCE' r
LIC ENSEDCONTRd DECLARATION
under provisions
I hereby affirm that ection7000)Olaml3cen3ofthe eressandof mfeh o sC9 e,and
nsCode, end my
Ii.e.1Section 7000) and
license Is In fus( and c.I 44, L}'i.—
LICK l
APPLIANCESRESIDENTIAL
JOB DESCRII'110N
a skq'
r^L.n(�
V
PANELS
DateLice
Date�ntm ( Q��� U'I MUP
ARCHRECTS C OaT1ON
rand my pl haR be v blfc records.
TO 2DOAMPS
OVER
OVER 1000 AMPS
SQ. FT. FLOOR AREA
S/SQ. FT.
SIGNS ELECTRICAL
Licensed profev(orul -
SPECIAL CIRCUIT/MLSC
OWNER-BUILDECLARATION
I hereby afRrm that l am exem row the Contractor's License Law for the
TEMP. OR POLE INST.
following reason. Biection 70U.5, Business arad Professions Code: Any city or
countywhlrh requires¢ permm
it torutruct, alter, Improve, dennllsh, orrepair
anystmenare priortolts hvrance,alsorequimtheappBcam for such permit to
file a signed statement that he is, licensed pursuant to the provisiom of the
Contractor's License Law (Chapter 9(commencing with Section 70001 of Divi-
Men 3ofthe Business and ProfessiomCode) orthat heh exempttherefromand
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by anyOUTLEIS
applicant fora permit subjects theappileant to a civil penalty of not more than
SWITCHESFIXTURES x,a^
Ove hundred delWe($500).
C] 1, as owner of the property, or my employees with wages as their sole
NEWREEDENTIALELECTRSQ.FT.
STORIES
TYPE CONSTRICTION
compensation, will do the work, and the structure Isnot Intended or offered for
sale (Sec. 70K B.since. and PNfeelom Code: The Contractors License Law
does not apply to an owner of property who builds or improves thereon, and
doessuch work himself or through his own employees, provided that such
I
OCC.GROIIIa
RIS. UNITS
Improvements arc not Intended oroffered for sale, If, however, thebuilding or
Improvement hsold withinoneyearofcompleliorytheowner-bu0derwl0 have
TO ea —
-
t rden of proving that he did not build or Improve for purpose ofvleJ.
Lj L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sao 7044, Business and Professions Code:
QTy. PLUMBING PERMIT FEE
FLOOD ZONE
APN
PERMIT ISSUANCE
The Contractor's License Law does nor apply to an owner of property who
builds or improves thereon, and who contra for such pRojece with s
egR(Pdor(s) licensed pursuant to the Contractor's License Law.
"Ell am exempt under Sec. B A, P C for this reason
ALTER -DRAIN hVENT- W
FEFt SUMMARY
W PROTFGT. D CE
DRAINS FLOOR ROOF, A 01N G .
FIXIl1ItFS PER TRAP
ANITA Y RECEIPT N
Y— N_
RECEIPT_NN
Y N —
R EB'Tp
KBUILMNGD[V[SION
Owner Da e%
WORKMAN COMPENSATION DECLARATION
❑1 hereby affirm that I have a certificate of consent to self -insure, or
certificate ofWorkeri Compematlon Insurance or a certified copy thereof(Sec.
MOO, Lab C.)
Policy N
GAS EA. SYSTEM -1 fNC.40 E
Com
GAS FA. SYSTEM -OVER 4 (FiYJ
FET$
Ified copy In hereby furniahed.
Certified copy is filed with the city Impectlon division.
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASETRAP
CERTIFICATE OF D(EMPTION FROM WOR KERS'
PAID
COMPENSATION INSURANCESEWER-SANITARY-STORM
(This section need not be completed lithe permit hfor one hundred dollars
Date Receipt#
EA 200E• -T
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y_ N_
($1016 rlev.)
I certify that In the performance of thewwk forwhich this permit Is Based,
WATER SYSTEM/TREATINGWorkers'
I shall not employ any person in any manner so as to become subject to the
Compenealun Uwe of California. Date
PAID
Applicant
NOTICEcome TO subject to the ager makiomng a Certificate suis Exemption,you
should become the Workers' Compensation Lab
mrmit of
NEW RESIDENTIAL PI.MB.SQ.FT.
Date Reeei t#
TOTAL:
BUILDING FEE
=at it
Code, you must forthwith comply with such provisions arthb permit shall be
thins be
deemed waked.
corvsraurnoN LwnlNc ACBNcy
SEISMIC FEE
I hereby affirmthat there hacomtructlon lending agency for the perform,
cam of the ..,it for which this permit b issued (Sec. 3097, Civ. C.)
Lander'. Name
Lender's Address
I cartitythatl have read thisappl1ratlonand statethattheabovelnformation
Iscormet. l agree to complywith all cityand county ordinances and nate laws
r TOTAL:
ELECTRIC FEE
a, -
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE -
FEES PAID:
relating to building comtructlun, and hereby authorise representatives of this
ally to enter upon the abovcmentldned property for inspection purposes.
e) agree to eve, Indemnify an d keep harmless the City of Cupertino
agai thebilltles, gmenm sand ex 9whlch rrayinaryw.y...
ALTER OR ADDTO MECH.
Date ReCei t#
P
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
ago t ren e ce of the ng of this Permit.
AIR HA NDLING UNI'T(OVER I O,000 CFM)
CONSTRUCTION TAX
SiBe.. o canontnctor Data
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUSM E ALSDISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Date Reeei t#
Wllitheapplicant or future bu oavpant store or handle havardoun
materhlasdefinedby theC pend Munt.P.ICud,Chaptrr9.IZ..d Iha
1 alth and Safety Glen 75531(a)7
Yes No
HEATING UNIT (OVER IW,000 BTU)
.TOTAW
VENDWTION FAN (SINGLE BESID)
ISSUANCE DATE
Y. applica turebu(Idingoaopant use equipment or devices
whichemit havrdouaairco i mlnantsasdefierdbythe Bay Area Air
Qua lity Management Win?
No
P p h
Pi V
BOILER-COMP OHP OR 100,DM BTU)
BORER-COMP(OVER 100,000 BTU)
4Yrs
havemadthe h ouarnderialsrequirementsunderChapler6.95of
the Callfemia Health k Safety Code, Sections 75505,25533 and 15534. 1
understand that if the building does not currently have a tenant, that it h my
I9I%1 pN�
IW
I9IP1 2 199
NEW RESIDENTIAL MECIL 'SQ.FT
respomlbility, to notify the occupant of the requirements which at be met
C
prior to Issuance of a Certificate of Occupancy.
CIIY I)r 7
ISSUED BY:
Owner or authorlad agent Date
TOTAL:
OFFICE COPY