23014APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Bauld ng Aaareaa: 2 DE LA
PERMIT NO.
A
23014 3 0 1 /il
G
one:
A . A A
fir•
CITY OF CUPERTINCuBUILDING DIVISION
APPLICATION / PERMIT
Contractor's Name. Lie. N.
'Architect/ 1 - . No:
BUILDING-ELECTRICALPLUMBING-MEC IAMCAL
CATEGORY CONTROL it
BUILDING PERMIT INFO
QTY ELECTRIC PERMIT FEE
Adareas
PQihBTISSUANCEx�
115�JOB
El
CONTRACTOR'S DECLARATION
'with Se aftfirmion? hurl er
APP[dANCFSRESIDENTIAL
JOB
Bupressan Preforapier9(commmc
lnenseI I. fon format Divfect. (theBminessa dPro(oslonaCode, and my
ivsloar3 fthe
Licers is I.I force and dLic. 0 1 �i
1i i
/ — ` ob5L
Ki f\\
PANELS
Date�Contractor
2014000AMPS
ARCHITECTS DECLARATION
(understand my plan shallw used as public records.
OVERIODOAMPS
SQ. Ff. FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
SPGCIALCItCUIT/M15C
OWNER. BUILDER DECLARATION
I hereby afRrrnthat I am exempt from the Contractor's License Law for the
7FMp,METLR ORIOLE IN'ST.
following reason.(Section 70315, Business and Profenslons Code: Any dry or
countywhich requiresa permit tocoatrud, alter, wpmve, demoilah,urrepair
anystrudure prmrto its lmuance,aho requirestheapplicant forsuch permit to
file a signed statement that he h licensed pursuant to the provisions of the
Contrzdor's License Law (Chapter9(mmmendogwith Section 7000 of Divi-
sion3 of the Busineaand Profeaione Code) or Mat he b exempt thercfromand
the basis for the alleged exemption. Any violation of Section 7MI.5 by any
applicant for a permit subjects the applicant to a rnil penalty of not marethan
POWER DEVICES
SWIMMING POOL ELECTRIC
OUILETSSWITCHESI•I)(TURES /�
VALUATED
Ova,
NOVA
NEW RESIDENTIAL ELECTR SQ.FT.
five hundred dollars arshe pro
I, as owner of the property, or my employees with wages as !herr sole
STORIES
TYPECONSTRUCTION
compensation, Wel it the work and thestructureisnot Intended or offeree for
sale (Sec. ainow and Code: The Contractors License law
'
to
don notoessuch loan owner offprough his o builds nemporimprwnded thaxand
apply f property
who doem hisownae. that
himselftIntended
OCC.CROUP
RES. UNITS
ntswork
If,ho eprovided
Improvementsarena IntendM oroofoo forsale.I(hower- the or
Improvement bsold wlihinoneycarofcompldbn,theownenwlldawlll have
erwilbuilding have
TO
N rden of proving that he did not wild or improve for purpose faide.).
[ as owner of the property, am exclusively contracting with licensed
contractors to construct the project (See. 7044, Business and Professions Code:
QTY. PLUMBINGPERMIT FEE
PERMIT ISSUANCE
FLOOD ZONE
APN
The Contractor's License Law does not apply to an owner of property who
Wilda or Improves thereon, and who contracts for such p(ojed, with a
ct
�gBt�aor(s) licensee pursuant to the Coniradmre License Law.
LJ 1 am exempt under Sec. B & P C for this reasonOUTS)
ALTER -DRAIN &VENT -WATER (EA)
FEE SUMMARY
gp�p�4y PROTECT. DEVICE
DE FEES
DRAINS FLOOR RDOF, AREA, GOND.
SANITARY Y_ N_
RECEPTN
Owner Data
WORKMAN COMPENSATION DECLARATION
01 hereby affirm that I have a certificate of consent to eelGlnmre, ora
38W, Lae ofWorkera Camperwtlonlaurance ora certified mpy ihenrof(Sm.
3800, lab Cd
FIXTURES PER TRAP
c"x
{ LTA% Y_ N_
I I RECEIPT N
GAS EA. SY NC.40 Ef5 1
\ 1... -• L`'
'PA FTE I Y N
RECEM'N
'r��I�g,,,
GAS F.A. SYSTEM-OVER4(EAI:A / �,
Compolite n Y
]BUILDING DIVISION FEES
ertmed copy is heed with the
ertiied copy is hereby fa is day iapectlmn division.
GREASE/IN u ASTE INTERCIe'
4
,,,aaa
*4NCl- �CK FEE
' II
GREASE p�;.IC
CERTIHCATEOF EXEMPTION FROM WORKERS'
PAID.
SEWER -SA ARY-S1OR.M EA. 200FT.
COMPENSATION INSURANCE
(This section need not becompleted i(the permit V (rn one hundred dollars
Date ReceI t#
WATER HEATER w/vENr/ELECTR
ENERGY FEE Y N
($100)orlem.)
I certify that in the pedormanceof the work forwhich this permit is Issued,
WATER SYSlT7.1/TREATING
I shall not employ any person in any manner se, a to become subject to the
Workead Compensation Laws of California. Date
PAID
Applicant
NOTICE APPLICANT: after making this Certificate Exemption, you
Date Rett•( t#
NEW RESIDENTIAL PLMB.SQFT.
TOTAL:
co
sowed became subject to the Worker'
a ro n is of the Labor
such p liti s or this
Coddecreed
eedfr most forthwith comply with such provisiomorihb permit shall be
dccrtrd revoked.
BUILDINGFEE
-
SEISMIC FEE
_
CONSTRUCTION LENDING AGENCY
Iherebyafftrm that there is a rastrudion lendingagency for the perform-
ance of the work for which this permit is Issued (Sec. 3097, Civ. C.)
TO ii
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
�^
L.cnders N.
Lenders Address
I cenifythail have read thisappliation and datethat theabove Information
fa, cored. !agree to comply with all dtyand county ordinances and state laws
MECHANICAL FEE
-
PERMIT ISSUANCE
FEES PAID:
elating to building consuudloo, and hereby authorize expedaentatives of this
city to enter upon the awvcmentioned property for inspection purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
ALTERORADDTOMECH.
Date Receipt#
SUBTOTAL•
against imbilities,judgments, consand expenseswhich may In anywayaccrue
aga Inst said City in cre aequence of the gra riting of this permit.
�w r
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLI NG UNIT (OVER 1 QW0 Cp)
CONSTRUCTIONTAX
'Ignatvreof Applicant/Contractor Date
IXFWI15'T HOOD (W/ DUCT)
CONSTRUCTION TAX PAID:
HALkR DOGS MATERIALS DISCLOSURE
HEATING UNIT (FO 100," BTU)
Will the appea of orfuium building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 2, and the
Date Recei t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
I With and Safety Code Sectlon 25532(a)?
❑ Yea No
Mrs
VFNfi LADON FAN (SINGLE RESID)
ISSUANCE DATE
WW the applicant wilding occupant use equipment or devices
which emit hazardous air contaminants as defined by the Bay Area Air
BOILER -COMP 0HP OR 100,OW BTU) -
Quality Mavgenaot District?
Y.e ❑❑ No
have read thehazardoua materials requirements under Cha per 6.95 of
�^$ A I
i
BOILER -COMP (OVp2100,0006N)
the California, Flealth & Safety Code, Sections 25505, 25533 cad 25534. I
NEWRESIDENTIALMECH. SQ.FT.
understand that if the building does not comently have a tenant, that it Ismy
responsibility to notify the occupant of the mquvements which most be met
prior to Issuance cfa Certificate of Occupancy.
110 V 2 0 1991
/x
V'r si�j`r-
ISSUEDBY: (�
Owner or authodzed agent Dale
'
I TOTAL:
OFFICE COPY