23969 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Eulldle project Iden llwtlonPERMIT NO.
BulldmgMdrem: _ 23969
03 � avers 6Gf �
e amc: o
fcC - �kc CITY OF CUPERTINO-BUILDING DIVISION ry
contranor'�Narni: c10 Noe APPLICATION / PERMIT 72
-1 � Z-
2 BUIL.DING-ElE MCAGMUMBINGMECHAMCAL CATEGCiRY CONTROL
Amhitm/Engineer. IJr.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. LICENSED CONTRACTORS DECLARATION
PERMTISUANCE
I hereby aHbm that laLicensed under satClupter AIPUANCESRESJ
EMA
IngwlthFenbn7000)ofDitlon3 otthe BuidnessamPmlesdonsCode,and
B DFSCRI'D NQS
Ifcewe Is In full fetpe d effect PANELS
Lite.Clare [} � LICI Z. —1
Date '7�14��4"i7 Contncror
ARCHITECTS DECLARATION XI' AMTS
P❑+o4zC lurdemoud nryplamahalbeused upublicrtmrda OVFRIODOAMPS SQ.Fr.FLOOR AREA f/SQ.FT.
E o U Limited Pmlmbnal SIGNS OFCTRICAL fln`. n. D IN
«<<�La OWNER-BUILDER DECLAMTION
nF P Ihertq a(Ormthatlam eaemptfRnthe Contranofs lJ¢rue law for the SPECIAL CIRCUIT/MLSC s; � 1 n P U T
0-2
'Q� following mas,on.5ealm 70715,Butlnm and Protmbru Cole,.My city or 6�f J
OZF� sun which a bmnsfm after, TEMP.METER OR POLE INST.
Fyey
county rtquBes hisou 4 prove,demoWh,or (0/10)f3
any ahuaud statement
ptna.a to the torwchpemdt a pig DEVILS DATE
S r Ole•tlgnr's statement the M b Irenem pursuant ft the ti ovbbv of the
Contntlor'e lJcerue l�w(Chapter9(mnvrcndng with Seabn7000)or Dlvl- ,tiylhlAgNG POOL IT ECMIC ._j
F O cion heads fo Butlnmand Pmlmin. Any or Nit heboimpt thert(comand VALUATION
Yl the heads for the alleged exemption. My violation d Section 7MI5 q any
p�
applicant fora permit subjects the applicant to a civil penalty d not anrsthan OUTLE[SSWITCHESF000URES
pQ� live undrecl dollars(S M. Vv�/
1,as owner of the property,or my employees with wage as their sole NEW R®ENTIAL FT TR SQFr. STORIES TYPECONMUCTION
compcneeim�,wifid w¢kand the Wunursbrot wended proffered for -
sale(Sec 9034,Buenev and Professions Code:The Contrscipts Llano law
7,�$g doesnotapplyto an UNITSw
orer o(pmpertywho bulbs orlmprvves thereon,and OCCGROUT' RFS
EE whodwwMmx
chworklfw
orthrgh hisown employee,Provbad that ouch
bapmvemeNsaremtmtendedorotleredfwu .ILhowever,thebulbingor T
impmverm a"wllhNomyearofcompletbn,thewvnerbuBduwilove
t raenof proving the he did not wild or Improve for purpae of mi,). QTY. PLUMBING PERMIT FEE
L u owner of the property,am eaclum
evely ntracting with Ibenseti FLOOD TONE APN
contractors,to construct the project(Sm 7DK Buslrm and ProlmloN Cade: PERMIT ISSUANCE
TM CoNrsGOra Lkxrue Law don not apply to an owner of property who
lou IALTER-0RAIN kVENT-WATER(FA)
ds or improves thereon, and who mrdam N far such p(ojewith a
111mrsed pursuant to the CmtactNa Lien law, FEE SUMMARY
BACK FLOW PROTEErf.DEVICE `urTSlDF FEES
m aempt under Sec B 4 P C far this reaeon
nen D DRAINS ETODR ROOF,ARFA,COND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RECEIPT a
❑I hereby affirm that I have a certlBan of consent to self-Iwre,or a F1)(N6 RPER TRAP SCHOCIL TAX Y_ N_
mecam cam d Worken'Compenelon Insurance or a¢riffled copy thereof(See. RECEIPT'
3800,Lab C) GAS EA.SYSTEM.I INC40UTITEES PARK FEE Y N_
PWB,a GAS U.SYSTEM-0VER 4(U) RECEIPT 4
^'aa cZy BUILDING DIVISION FEES
-I—TCerilned copy b heregtuMe city GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK It
L�Jy Certlfvd ropy b filed with the city Inspection division.
CERTIFlCATE OF EXEMri'ION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARYSIORM EA NIFr Date Reaei t#
Trhbsenbn need nn h completed tithe pertNt b(morehundred dollars
fStfI mrBlm.l WATER TREATER W/VENT/MIXTR ENERGYFEE Y N
i 1¢rtify that btta perbrmn¢olthe work for which this permit is Issued,
1 shell net employ any person In any manner so as to become subject to the
WATER SYSTHJ./TRUTING
Workers'Campeuation Ia.w of Gllfomb.Date PAID
O Z NOTICE` NEW RESIDENTIAL"B. SQFr. Date Re f t#
Z O NOTICE TO AITLICAM:ILafter making thb Crrilfiate ofEumptbn,you .
ehauld lxcome sub}ct to the Woh<rs'Compewtbn provbbm of the Labor TOTAL
W N deemed revolvtlarthwhh empty with such provbbrs orfhb pemdt shall be
� j deemed revoked. �e
W CONSTRUCTION LENDING AGENCY ' SEISMICFEE
a IhembyafOrmthat there b a mretmnim lending agency forthe perform ELECTRIC FEE
7 Z ance of the wahfprwhk:h thb permit bfewed lSee 3097,CW.CJ TOTAL
O O Leme/e Name PLUMBWGFEE
LL F L mer.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Iceriilythai l have read the appBatlonard state thatthe above mfornutlan ��
bcorrect.IagaetocomplywithaUWyand=ntyordmanonandmate La PERMIT ISSUANCE FEES PAID
} N relating to wilding mrutmmm�,and hereby wthmiLo ew
reprentatioft,is
Z city to enter upon the awvcmentbisd properly far inspection purposes. ALTER OR ADD M MBCK
to U btan keep humm the City of Cu peribo Date Recei
[#
egainatWBies,Nd unts,mead sPeoaaa,
Welch may many waysmue AIR HANDLING[INTI(f010,0D0 CFM) SUBTOTAL:
age Wt old City N conryme
sueof the gramdL
Starting at this pe
ALR HANDLING UNIT(OvFx IO,WOCFM) CONSTRUCTION TAX
'the
Applicant/Contractor Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wllltheo a ppllaest¢totam wlldinggocupant eororhandle haaardous HEATING UNTT(TD 100,000 BM Date Recei l#
material as defle d bythe Cupettlo,M.mdpal Code,Chapter 9.11,and the
Yn
Flealth and SaIdy Code Secd.2M31W9 HEATING UNTr(OVER DID,=BTU) TOTAL: -
RRill No
ill the applicant or future wilding occupant use equipment ordevbs VFN71LATIONFAN(SINGLERFSID) ISSUANCE DATE
which emit loundous air as deOred by she Bay Area Am F� p ay ' D
Quality Management DWrlcl7 11011.ER-COMP OM'OR 100,000 BTIF) f
Yn ❑❑No
1 have ad the harallorrs materials requ imments under Chapter 6.95 of BOI.ER-COMP(OVER 100,000 BTU) JUL 14
the Ca llfomb Health 6 Safety Code,Sen ion.,25505,25533 and 25534.1 ,sasrs� �e J
undrnta od that 11 the building does nal currently have a trivial,that It b my NEW RESIDENTIAL MECH. SQFr. a���VLJ Al/v`Y
responsibility to notify the occapard d
the requirements which most he not
p y yyaa caCnmale Oem aneyy 17Y U1, Wr-rnlury
.owner or awrtt Date ISSUED BY
L
OFFICE COPY