23237 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Pm'em Identification 7 PERIETENO.
Building Address: 23237
�C i � z
one: A AL DAM
wnera ame� T �g;j,? CITY OF CUPERTINO-BUILDING DIVISION q Z
Contractors Name: �a Lit.rN�a: C APPLICATION / PERMIT l
Ant co lI/, A.a.a.S CSI-, r£�l�J2,5e 1?I aq3 BUILDING-ELECTRICAI_PLUMBING-MECHANICAL CATEGORY CONTROL It
Architect/Engineer. Lic.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ ❑ ❑ N
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commenc APPLIANCE4.RESIDENTIAL JOB VOCRNTION
ing with Scalon 7000)of Dlvlslon 3 ofthe Business and ProfessioasCAde,and my
Lfcnx is in fullfarpy}not kf N n yam^u S PANELS AAA sss
License hL C' J v rF •J • T V I e
Date—`Na--s'aJl=�-id^d�—Contractor C.+t//..fms s t.s��le+ r ` y
ARCHITECTS DECLARATION 201-1000 AMPS
Po�92O I understand my plans shall be used as public records. OVER10DO"I'S SQ.FI.FLOOR AREA S/SQ.FE
E Z Licensed Professlanal SIGNSELECTRICAL n
ya OWNER-RNLLDER DECLARATION
E LARATIOrbLlcenxGwforthe SPEC)ALCIRCLET/MLSC ,A L E D I N
Iwing son.(hatlamexem f P I E R
7.9 p following reason.(Section 7071.5,Bmines and Professbns Code:Any city hor e
OMf'W countywhi&mquU aper ttowmtma,alter,impmve,demollah,orrepMr T�"IP'ME[71t OR1'OLE INSI.
any structure prior to Its lasuance,also requires the applicant for such permit m POWER DEVICES n
E c file a signed statement that he Is licensed pursuant to the provisions of the 2 7Z
Contractor's License Law(Chapter 9(commencing with Section A)00)of Divi- SWR.(MING POOL ELECTRIC N
sion3ofthe Buslnev dProfemionsCodc)orthathebevempt there(romand'
Q �' the bash for the alleged exemption. Any violation of Section 70313 by any
' ¢=
applicant(Ora permit subjects the applicant to a civil penalty a..nnre than OUMETSSWIMILESFIXTURES
r five hundred dollars(SM.
Sn ❑L as owner of property,or employees with wages as sole NEW RPBIDFN7IALELECTR SQ.FT. STORIES TYPE CONSTRUCTION
P perty, y emp oy ges a
f= < compensation,will d o the work and the structure b not Intended or offered for
0 sale(Sec 7144,Business and Profemiow Code:The Contractors Lt..Law
( 2 does not apply to an owner of property who Wilds or Improves thereon,and OCC.GROUT' REB.UNITS
C• who doessuch work himself orthrough his own employees,provided that such
Improvements arc not intended oroffered forsale.If,however,thebuilding m TOTAL:
Improvement b sold wi W n one yearof completion,the owner-W Bdcrwlll have
thrden of Proving that he did set Wild or improve for purpose of sale.). QTy, PLUMBING PERMIT FEE
FLOOD LONE APN
L as owner of the property,am.exclusively Busi contracting with nslicensedCode PERMIT ISSUANCE
contractors to mmwn e L project(Sec,appy Business and of protons Code:
The Coor Improves
License law does not apply to an owner of property who ALTER-DRAIN VENT-WATER(EA)
builds or Improves therron, and who contracts for such p(ajecv with a
Iff,dor(s)Immed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ 1 am exempt under See. B &P C for this reasonOUTSIDE 17EES
Owner Date
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
WORKMAN COMPENSATION DECLARATION RECEIPT N
01 hereby affirm that I have a certificate of consent to self-Insure,ora c'PER TRAP SCHOOL TAX Y_ N
Certificate of Workers Compensatlonlnsurance RECEIPT N ora certified copy thereof(Sec. GAS EA.SYSTEM4 INCA OUTLETS PARR FEE Y N
RECEIPT I,
GAS M-
EA.SYSTEOVER 4(EA)
Com anv
CedirTlfletl copybfiled wishh tthe BUILDI:CG DI VISION FEES
�Ceried copy b herebytd. T CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
' the ccity inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRV' PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200ET. Date RLYCI 1#
(TMs section need not W completed If the permit b for cam hundred dollars
(SI IralWATER HEATER W/VENT/ELECTR ENERGYFEE Y N_
1 really
that in the performance olthe work for which this permit is hexed,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers Compensation hwa of CaOlOmis.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQFr. Date Recei t#
Z O NOTICETOAPPLICANT:Ilaftcr.a .gthb Certlllcaleof Exemptlon,you
fshould become subject to the Workers Compensation provisions of the Labor TOTAL:
V3 Cade,you=at forthwith comply with such Provisions orthb permit shall bas
W deemad revoked. BUILDING "E
W
a CONSTRUCTION LENDING AGENCY SEISMIC II-
I hereby affirmthat there b a construction lending agency for the perform ELECTRIC FEE
Z an of the work for which this permit b Issued(Sec.3097,Civ.C.) TOTAL:
(� O lend(,.Name PLUMBING FEE _
ly F Lendersaddre a QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W is cl cenifythat I have mad this applicationand statethatthe above information
rlem.l agree to comply withal)city and county ordinances and state laws PERMITISSUANCE T' S
D FEES PAID: 1
} N 'relatingtobuilding construction,and hereby authorize representatives o,this 4 6
F Z city to enter u Pon the above-mentioned property for inspection put ryoses. ALTER ORADDTO MECH.
_ (W agree to save,indemnify an d keep harmless the City o1 Cupenlno �T ate ReCeipt#
agar abilities,ydgmenb,coka apenxa which may in anywayaccrue AIRHANDLINGUNR(f010,000CFM) V SUBTOTAL:
aga tsaid City Inc egranting permit.
AIRHAND1_INGUNI1E(OVERI0,000CIM) CONSTRUCTION TAX
ig azure of Applicant/Contractor ate(! EXRAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building Occupant store or handle hazardous HEATING UNIT(TO 100,000 BITE Date ReCei t#
material as defined by the Cupertino Municipal Coda Chapter 9.1 2,and the
Health and Safety Cade Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
F1 Yea M No Lw
Wllltheapplicant or future building Occupant uta qulpmeat ordeviccs VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which emit hazardous air contaMmnts as defined by the Bay Area Air
Quality Management District? BOILER-COMP DEEP OR 100,01)(I BTU) P A ' p.
4Yes No
have read the hazardous materials rcquircmenh under Chapter 6.95 of BOILER-COMP(OVER 100,000BTU)
the California Health&Safety Code,Sections 25505,25533 and 25534. I JAN 29 1992
understand that if the building does not currently have a tenant,that it IS my NEW RESIDFN TIAL MECH. SQ.IT.
rapomibility to notify the ocau pant of the requirements which must be met
prior to Issuance of a Certificate of Occupancy.
Cilli VF C&CM I RYU ,
Owner or authorized agent Data .c`-
TOTAL: ISSUED BY: �•-�ls�V V`V ,
OFFICE COPY