23544 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pru'M ldentifeation PFR.WT NO.
Building Address:
23544
_311 .
IP
ILv Y4F VrGP�C. C,G_�xti �e CITY OF CUPERTINaBU1LDING DIVISION �Z
C trocar' N Lic.Na APPLICATION / PERMIT —
r CA RY CONTROL.
Arehftect/Erpeaer. Na BUILDINGELECIRICA4I'LUAIBINGMFLHANiCAL
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE ❑ 1:1 ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am llcersedunler provisions.(Chapter 9(.c, APPLIANCES-RESIDFNHAL pB D6C ON
Ingwah Section force and cffdon3 ofthe Butlnmand PmfesdoruCode,and 1�
lberme n in full for¢and affect. PANELS
eCla
Date m
Lb.I
Date G011traaar
ARCHITECpS DECLARATION XII-LINO
W0W 7 I understarid my plaru,hall be used n public records. OVER I"AMPS SQ.FT.FLOOR AREA S/SQ.FT.
`�j Licensed Professional SIGNSELFLTRICAL
6 OWNER-BUILDER DECLARATION
I.., / I hereby&farm that l am e, eryt from the Contractor's License law fee the S'ECLILCTRCUIT/MISC
Z
following¢&eon.irectlon7m15,Baenm and Profmbu Codr.Any dtyor TP]sfP.METQt OR POLE INST.
�WQ anyty nhre tolres apandit am rrutl,alter,theapmve,demsu&p rrepo
any evumrc pit¢tent that
he Es aborcd pursuant W thel, ro sac res of t e
f5 K�I 5 01e a signed statement thst he Es licensed pursuant b the proWbv of the TOWER DEVICES
Co diset.e.Llcnme I.w(Chapter 9(commencing with SMbn 7000)of DIv1-
F,�O;J ebn 3 of the Bunten and Profmbhat rsCesIO or the b exempt thertfromand SWadMING POOL ELECTRIC VALUATION
P Y.'•_77 the bash for the alleged exemption. Any violation of SMbn 7RH5 by any
appU..t fora Parnell,srbjeatatheapplkant to+elvil penalty of not mora than OUTLETSSWITCHESFIXTURES .
C flvi(�un s ed owner ars ofthe pp. SQ}7, SIOIUFS TYPECONSTRI. TION
(_J L d.weer of the property,or my employer wfih wages as their vole hEW RESIDEN77AL ELFS`[R
compere d wWdotk wwk+rod thestractu¢6not IrdeMedor.!feted for
sak(Sec 7054,Businui and Prde,bbv Code The Contradots L4.Taw
2- donot apply to aowner of property who builds or unproven thereon,and
c.%^ n n whodonsuchwork hirselforthrough his own employees,provided that sueh OCC.GROUP RFS.UMTS
Improverrcms art not intended oroffertd f¢sale.If,however,thebuBdingor TOTAL
improvement bsold within oneyearofc¢npletbRtk owner-builderwiD have
t en of proving that he did not nrud or improve for purpose ofsale.). QTy. PLUMBING PERMIT FEE p DZDM APN
4 as owner of the property,son a.hosE ely oan—u",
nwed lf¢n,eod PFRA4IT'ISSUANCE:cnntrm¢s to construct the project(Sec 7014,Ri dram and IMesiom Coda:
The Contdol,Lkei se law dm nm apply to an owner a property who ALTER-DRAIN 4 VFM-WATER&ld
build,or anpnevvs theme ,and who.room for such Mines with
-AlraeturW licensed punwnt to the Contractors Ll¢nr Law. FEE SUMMARY
BACK FLOW PROTECT,DEVICE
U I am e,emp uidm Sec B k P C for this rtawn
•
DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y_ N_Owner Date
WORKMAN COMPENSATION DECLARATION RECOPI'a
FIXEURps PER TRAP SCHOOL.TAX Y_ N_
❑1 hereby affirm that I have a nertlfcate of consent to self-nsurc,¢a RECEIPT a
M WabC Worken'Campemstlon lmunn¢ora¢rifled copy thrrof(Sec. CAS F.A.SYSTEM-1 ING4 OUTLETS �3
3300,lab CJ �.Oy PARK F'FE Y_ N
Cam s GAS EA.SYShM-0VER 4(FA) DINGRECEDIVISION
T I
Y BUILDING DI V ISION FEES
CerWed.py 6 hereby famished. eft&ISE/INDusIRL WASTE INTERCEPTOR PLANCHECK FEE
Coni ied copy 6 filed with the edy impecbn division.
CERTIFIGn OF EXEMPTION FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCE
Rh6,ectbn n¢d wt kcernplatedifthepenest 6fe omhundreddolW SEWER-SA(JR'UtY-STORM EA XNIFT. DB[C Rcoci I#
at )or less.)
ImriflfWAT HT:-.ATPRW/VENT/ELECTR ENERCYFEE Y N
I¢ ythet nthe pedomun¢.fthew¢k(orwMch Wspemdt6bsued,
I ehaB not employ any person In any manner.as,to become subject to the.DateWAM SYSTIM/TREATING
Workera'Comv
pention laws of Ca Womb
PAID
0 Z Applicant . NEW ItE51DEN'HAL PIMB. FT. Date Reuel [P: #
Z NOTICE TO APPLICANT:If,after eking this Cerlfiate,of Extirpator,youeSQ
should become subject to the Workers CopaneaLa
tbn prodate.of the bor TOTAL:
mr' m
(1) Coda you at forthwith comply with such provisions or this pemJt shall be
LU j denn d rwok dBUILDING. _
dCONSTRUCTION LENDING AGENCY SEISMICFEE
I hereby affUmthat there Is.construction lending agency for the perform ELECTRIC ELECTRIC FEE
Z m of the work wh this perret nedec 30Th,CIv.C) TOTAQ
V O arhk66s1<ndere Nares I PLUMBING FEE _D
LL F Iender'aAddmb, QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
WI¢ rify that l have read this appBniWit and state that the above nforratims
6corrtd.lagrtet.complywah all Wyant countyoednanmand state laws PERMITISSUANCE FEES PAID'.
} C rdmingtobulldngmvmro m,andkrebyauth.r mprmnuttwafthb
Zetytoenter upon the abovcmentioned property for uopdbn purposes. ALTER OR ADD TO MECH. Date Recei t#
_ (We)agree to save,tndemn �lfy in d keep harolethe City of Cupertino
age no" butt Ndgmente rd e,pe�whkh rtay In anywayacvae AHt HANDLING UNIT(TO 10,000 CFM)
SUBTOTAL:
uidC . n¢af a ngdth6perwit
AIRHANDLING UNIT(OVER 10,m0CFM) CONSTRUCTION TAX
Si m.f Applla / tr>nro a EOIAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
k1A USMATERIALSDISCLOSURE
Will the appBant or(utu¢building ocvpant door ha Mie hawdws HEATING UNIT(-10100,0f100RI) - D31C RCCCI t#
mate la,definedbythe Cuperbo M.NdpalCode,Chapter9.IZandthe
li,aithaMSafetyCade Sectlon25537(a)7 HEATING UNIT(OVER 100,000 BTI!) TOTAL: -Q
WYn P
W
lfl the applfam¢qtum building onvpant use equlpned or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which enuth rduu,ab contambsnt,as defined by the Bay Area Ab p A I D
Quality Management D6trkct7 BOR.FR 000-CDMP OFT OR 100, BTU)
Yes �No
I
have mad the hes ous materials requirements under Chapter 6.95 of BOILER-L'OMP(OVER 1M,"BTM
the California l lealth k Safety Code,Seeti.im 7550.5,25533 and 25535. 1 APR 21 1992
uMmtand that lithe bn 6 building donot have a tenant,that It my NEW RESIDENTIAL WCH. SQFT
reapom@W)`to notify the oavpar t d the requirement,which nus be root
prior to 6tua race of a CerWate of Oma pancy.
CI I t r GUrcn l uru
Owner¢sulhorlud,gem Date ISSUED BY: 0
'TOTAL
OFFICE COPY