23553 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prosed Identification - PERMIT NO.
Building Address: 23553
Btu
Mr a In.n.:
CITY OF CUPERTINO-BUILDING DIVISION Lit .V� Z
G ° •. me: Lk.No: APPLICATION I PERMIT ^
prchitm/ ncer. BUILDING-ELECTMCAI.PLUMBINC-MECHAMCAL CATEGORY CONTROLN
Lk. o
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. PIRMITISSUANCE 1:1 E] ❑
LICENSEDCONTRACEOR'S N A IO
I hereby a fflrmthatlamlkmn dunderpr b[oK.ofChapter9(mmmmI, APPUANCESRESIDENIAL JOB DESCRIPTION
Ingwlth Sed on7000)of Dlvlslon3ofthe Buslnessand ProfeulonsCode,and my
I IB In full fo d effect, PANELS �s /���Y�a+r'
Llcen b k.p� - S .COP
Dat Cantncror �� 201-10DOAMPS
ARCHITECT'S DECLARATION
q�q�uu
Ob I understand my plan shag be used as public remN, OVER 1000 AMIPS SQ.FT.A.00R AREA E/SQ.ET.
k Llcenaad Prferolanal SIGNSELECTRICAL
<6 OWNER-BUILDER DECLARATION
Ian SPECIAL CIRCT/M15C
ZF- Thereby affirm that[cum exempt fromtheCnnl ractohLlmnm Law for the _
Q following reason.(Section 7011.5,Business and Professions Code:Any city or
Key cmntywhkhrcquimaperrrdttowmmd,alter,lmprovgdemaibh,orrepair TFAIP.METFR OR POLE INST.
anystrudure prior to its Wuance,aborequim theappBont fmsuch permit to POWER DEVICES
file a signed statement that he b licensed pursuant to the pro haoru of the
Contradoe.Liceme,Law(Chapter9(commencing with Stolon 7000)of Divi. SWIMMING POOL ELECTRIC
f. OJ elon3 of the Buelnessand Pref.ima Cade)arthe heb excmpttherefromand VALUATION
E5< the basis for the alleged exemption. Any violation of Section 7011.5 by any OUTLETSSWITC1ffSFI(11IRES
O applicant for a permit subjects the applicant to a civil penalty of nor more than
�j flue hundred owndoler
of the XB. STORIES TYPE CONSTRUCTION
f`C NEW RE9DENITAL ELECTR }7.
�n ❑I,as owner of the property,or my employees with wage as offered
sok
c m(Sac.lion,willdothework,andthes C da:Tha C. tradetended o.1ce.Law
�pa' .1.(Sac.Till,Buslnaasand Pro(emloru Code.The Contractors Llcerue law
$$ does notapplyto an owner of pmpertywho bulldsor improvesthereon and OCC.GROUP RES.UNITS
whodoessuch workhtmeelf orthrough hisownemployeee,provided thalsuch
Improvements are not Intended oroffered formic.I(howeveq thebullding or TOTAL:
improvement bsold wlthinoneyearofcompldbMtheowner-bulderMll have
tlallurden of proving that he dal not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD TONE APN
Lj L as owner of the property,am exclusively contracting with licensed pggMT'I'ISgUANCE
contractors to construct the project(Sec.7040 Business and Professions Cade: ��
The Contractor's License law does not apply to an owner of property who ALTER-DRAIN At VENT-WATER(EA)
builds or Improves,thereon,and who contracts for such plejecta with a FEE SUMMARY
cWfadm(s)Bcaneed pursuant to the Contractors License Law. BACK FLOW PROTFLT.DEVICE
L.J I am exempt under Sec B k P C for this reason
OUTSIDEFTES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner -Data RECEIPT I
WORICMAN COMPENSATION DECLARATION pIX�PERTRAP SCHOOLTAX Y N_
[:]I hereby affirm that I have a certificate of consent to self-insure,or a RECEIPT N
mrtlfleseafWorken'Comperoation lruurancema certlled ropy thaw HSm.
3800,lab C.) GAS EA.SYSTEM-]INCA OUTLETS PARK FEE Y N
1RECEIPT Y
Ca�'oliryY_—q GAS EA.SYS EM-OVERd(FA) BUILDING DIVISION FEES Ce fI d m-py– ¢re m ed. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
ertRletl ropy b filed with tM tlty Irupedlon division.
CERTIFIGTE OF EXEMPT ION FROM WORKERS' GRP
PAID
COMPENSATION INSURANCE S SANITAR STORM EA.2t10FT. Date Reeei tic
(This section need net be completed If the permit b fm one hundred dollars
($100)mlm.) WATER HCATTR W/VFM/k].ECTR ENERGY FEE Y N
rm
I certify that In the perfaanee of the work forwhich this permit is Issued,
I shall not employ any person In any manner so as to become subject to the WA77R SYSTEM/TREATING
W.ek¢re'Cmnpannatlon Lawsof Callfomh.Date PAID
Applicant NEW Recei tN
Z Z NOTICE TO'APPLICANT:If,after making this Certificate of Exemption,you NEW RE57DEN77AL PfMB._SIFT.
should become subject to the Workers Comperuatlon provisions of the Labor TOTAL:
fA Code,you must forthwith comply with such provisions orthh permit shall he BUILDING
W j deemed revoked.
0. F3 CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby aflrm that there is a constructor,lending agency forthe perform ELECTRIC FEE
Z ante efthe workforwhlchthb permit Is bwed(Sec,3097,Civ.C.) Tam
—�
p0 lender.Name PLUMBING FEE
LL ~ Lendce.Addm. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I certifythat l have rcadthb appliettionard Mamthattheaboveinformation
1 bcerred.l agree to complywith all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. relating to building renstrudlon,and hereby authorize representatives of thin
N
f. city to enter upon the above-mentioned property for inspection purposes. ALTORADDTOMECH.
2 (We)agree to save,Indemnify an d keep harmless the City of Cu partlno Date ReCel tit
V
against liabilities,judgment,ostaand ex pen swhlchevylnenywayacerm AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
IS o 1pgt eOCRy 1. u;.2.4a g"ra �n�gpar this permit. �� AIR HANDLING UNIT iOVFR 10,000 CFM) CONSTRUCTION TAX
SII/, fAp anit/ContrMraactor a' "'tea o,e.`Y7j EXHAUST HOOD(W/DUC'D CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant or futum building occupantetore or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei tp
material as defined by[be Cupertino Municipal Cade,Chapter9,l2,and the
Health and Safety Cadre–Scction 25532(x)2 HEATING UNIT(OVER 100,000 BTM TOTA • --
Fly. , aL _
Will the applicant orfururc building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air conGmiwnts as defined by the Bay Area Air
Quality Management Dbtri BOILER-COMP DHPOR 100,0(0 BTM
❑Ya o p�
/ Ihavcrcadthehaza ou.,.terlalsmquimmentsunderChapter6.95of BOn.ER-COMP(OVER 100,000 BTU) Y
the Glifornu Hezith A Sifely Code,Sedlons 25505,25533 and 255U.1 l
understand that If the building does not currently h veatenant,thatltlsmy, NEW RESIDENTIAL MECH. SQ.Ff
re.ponaibility, n
to dity the occupant the require is which must be met �PR 22 1992
prior/gRlua�e f�Ile sof paney��Qi
Own ravihorized agent a LLLIIIyyy Date TOTAL ISSUED BY-. �
OFFICE COPY