23451 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY,
Building Protect Identification s PERMIT NO.
Building Address:
0 (o615 23451.
ser a ante: r ones`
�% Z,%—S S4 I' CITY OF CUPERTINO-BUILDING DIVISION
Contractor's Name: Lin.Nm APPLICATION / PERMIT
BUILDINGELECTRICAL-PLUMBINGME MCAL CATEGORY CO
ec/Engineer. Lie No:
QTY ELECTRICPERMIT .E BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ ❑
LICENS EO CONTRACTOR'S DECLARATION
I herebymflmlhefDiviscrosedueder Busimvidonae(mionsc(mmdrn API'LIANCESRESIDE L P�JOB�$IL'I'ION
Ingwith h,ion7000)of Dlvfftne. (the Buelneesandl'rcfeuloneCade,and [[\`^6
Iiconse le In fullfors and effect. P
Liconm Clam C1.or L . a
Dale Contratorrz� v f�+'Iv�ln
ARCHITECTS DECLARATION 1") �
µQ�p❑O 1 understand my plana shall be used m public records. O ka.� ^ f/fQ.Fr.
E (/ Licensed Profemlaml SIGNS ELEC K
VAlt
�6 OWNER•BUILDERDECLARATION SPECIAL UIT 15C
A l.., IherebyafRrm that l am exempt from the Contractors LTconse Law for the
o q following reason.(Section 7011.5,Business and Professions Code:Any city or
r ZI"u) county which requires a permit to construct,alter,improve,demolish,or repair TEMP.M � RMR
PDLE INST.
signed
prismab Wu
lanceb
,eorequireathe applIcantforauch permit to POWER EVICES
V file a signed statement that he Y licensed pursuant to the prevblmu of the
3u. Contractor's License Law(Chapter 9(commencing with Section 7000)of Divl- SW)MMIN POOL ELECTRIC `..
VALUA`+ •
SOS mon3oflhe Buslnem endlarofealoruCode)arthm he bexempt thertfromand ^
the basis for the alleged exemption. Any vlolation of Section 7031.5 by any S
ppBcontfora per mit subjects the applicant to a evil penalty ofnat morethan Ow
OUTLETSSWI'PCIiFSFIXTURPS
a(�•e yundmd dollars(SSM. NEW RESIDENTIAL ELFGTR_SQ.FT. STORIES TYPE CONSTRUCTION
�n I,as owner of the property,or my employees with wages as their sole
c pensetion,wllldothe work and lhestrutum bast intended or offered for
O mto(Soc.7044,Buelnmsand Pmfemlons Code:The Comntofe Lt..IA.
does not apply to an owner of property who builds or improve,thereon,and OCC.GROUP RFS.UNITS
whodoessuchworkhim l(arihrough Msownemployzm,providedthatsuch
Improvements are not Intended oroffered forsale.If,howevegthebulldingor TOTAL:
Immen
provet bsold MthinoneyearofcompletoMtheawner-WUderwRl have
lt�urden of proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN '
u L as owner of the property,am exclusively contracting with licensed PERMITISSUANCE .r•�
contncon to mrutrut the project(Sec.7044,Business and Professions Cade:
The Conlnctme.License!a a dont sat apply to an owner of pmpar y who ALTER-DRAIN&VENT WATER(EA)
Wilds or Improves thereoM and who contracts for such piojeca with e
cgetr+tmW Breneed pun asm to the Contractor's Llcorue Law. FEE SUMMARY
U I am exempt under Sec. B &P C fordhb reason BACK FLOW PROTECT.DEVICE OUTS]QF FEES
_
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEB'F M
WORKMAN COMPENSATION DECLARATION RD(TURES•PER TRAP �,. SCHOOLTAX Y_ N
❑I hereby affirm that I have•cocif tate of consent to self-insure,or a RECEIPT R
mrtlflmteofWorkwWCompev tfonlmumnmoracodifW copythereof(Bert.
3800,Lab C.) GAS EA.SYSrEM.I INCA OUTLETS PARK FEE Y_ N_
Policy M RP.CEI'T 8
CmCified copy b hereby GAS F.A.SYSTEM-OVER4 CPA) BU ILDINGDI VI SIOf N'FEE
0cemnea ropy Is rued with the city inspection division.. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE S
—[a p
CERTIFICATEOF EXEMPTION FROM WORKERS' GSM TRAP PAID '
COMPENSATION INSURANCE SEINER-SANITARY-STORM EA.200F1'. Date Recei t#
RM1isneclon need not he completed If the permit b dollars one hundred dalla
(S1m)orlete.) WATER HEATER W/VENT/ELF.CTR ENERGYFEE Y N
I cortify that In the performance of the work for which this permit is Issued,
I shall nm employ any person In any manner n m to become eubkt to the WATER SYSTEM/TREATING
Wmkers'Compematfon Laweof California.Date PAID
—
z Z Applicant NEWRESIDENITALPLMB. SQPF. Date Remi t#
Z O NOTICE TO APPLICAMa,efter ma king this Certificate of Exemption,YOU
Hshould become subject to the Workers''Compewtlon provisions of the Labor , ` TOTAL:
N Code,you must forthwith comply with such provisions orlhla permit shall be V
BUILDING FEE
W 9 deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
IL ° Iherebyaf#rmthat there b a construction lending agency for the perform- L ELECTRIC FEE
M O anmofth.wo'kfo'rwhkh this permit is bvaed(Sec.309'/,Civ.C.)
l endzla Name - PLUMBING FEE
U.U1 I- Lender's Addresa QTY. MECHANICAL PERMIT FEE r
O W ImAifythatlMvenadtMapphl tidnandmatelhattheaboveinforevtim �� MECHANICAL FEE
1 ismrret.I agree to comply wllhall city and countyordinances and mate laws PERMIT ISSUANCE LIEFEES PAID:
>_ N relating to building construction,and hereby authorize repro:ntalWes or this
city to enter upon the above-mentioned property for impetion purposes. ALTERORADDTOMECH. '
Z (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
V against liabilities,ydgments,costs and expenses which may In any way amue AIR HANDLING UNIT CIO 10,000 CFM) SUBTOTAL'
ago Cityi
it
gof tyle psnnit.
W.42— AIR HANDLING UNIT(OVER TO"COM) CONSTRUCTION TAX
SignateremApplicant/Contracor Date FXITAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAI
HAZARDOUS M RIALS DISCLOSURE
Will the applicant or future building occupant store or hand In hazardous HEATING UMT(T0100,000 BTI!) Date Reoci t
mmemm as defined by the Cupertino Municipal Code,Chapter 9.12 and the
Health and SafetyCade Setion 25532(a)7 HEATING UNIT(OVPR 100,000 BTU) TOT
RYea sLa—��No
illihe applicant orfvtum building ompant use equipment or devices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which emit hammlous ab oomamlrunts as defined by the Bay Area Air
Quality Management District? T BOILER-COMP DHPOR 100,000 BTU)
' Yes No
' Thave read the har.9 us materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
The Calffomia Health&Safety Code,Secloru 25505,25533 and 25534.1 MAR 27
understand that if the building does not crrently have a tenant,that it is my NEW RESIDEN77AL MECH. SQXT 1992
reapomibility to net By the occupant of the m piromen.which mum be met
prior to issuance of a Certificate of Occupancy. /� CI
I�Y Ur CUrtTu
Owner or authorized agent Dace A ISSUED BY:V
OFFICE COPY