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23588 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALLPOINT PEN ONLY Buildingm P 'ect Identification '+ PFRMTTNO. BuOding Address: - O53q - 23588 C �" S • refs Name: one: P11 11 CITY OF CUPERTINO-BUILDING DIVISION'. - Cnn° rtee N Lie.N.: APPLICATION / PERMIT — -- 11 Architect—�/Engineeen . Lie.N. 0f1ILDINGELECTRICALrLUM01NGMFGFUMCAL CA AY CONTROL X QIY ELECTRICPERMIT FEE BUILDING PERMIT INFO Address: PERMOTISSUANCE �° IC71 I`QII LICENSED CONTR under provisions Ihereby aB4mthu am Dtvisimsedundustrun Wonsof Cha)Rer9(mmmm APPEANCFSRESIDENTUL JOB DESCRIPTION Banish Sectlon7000)o(Dlvielon3oflhe Buslreuand ProlnJoneCode,and my , license lCie NB force and dfed. PANELS DateLi Clam Llcp Dale - Contnrtor tIC�`tM` Vow ARCHITECTS DECLARATION 200-IWDAMPS ren Z 1 understand my plans shall be used as public records. OVER IOW AMPS SQ.FT.FLOOR AREA $/$Q.Fr. ❑O Licensed Pr.feselolal - SIGNS ELECTRICAL . 6 w OWNER-BUILDER DECLARATION G SPECULCIRCUIT/MLSC 7 p,. I hereby affirm that I am exempt from the Contractors Licenselaw for the ' O rs following ream.(Section 70315,Business and Professions Code:Any city or TEMP METER OR POLE INST. - P county which requires a permittocorutmct,alter,Improve,deniollsh,or repair .� anystructure priorto Its issuance,also requireslheapplinnt fonuch permlt to POWER DEVICES Ble a signed statement that he is licensed pursuant to the provisions of the �w� Contractors License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC - k- s1..3.fth.0usinnaand ProfessionsCods)mthat he a,exempttherefromand VALUATION- _ 0 O D O the basis for the alleged exemption. Any violation of Section 7031S by any OUTLETSSWHCHFSEXTUAFS applicant fora permit subjectsthe applicant to a dv11 penalty of not more than Q ❑❑❑���.��e yyynnndred dollars(g.S00). SQ,FT. STOWES TYPE CONSTRUCTION u• NEW RESIDENTIAL ELFLTR aownerll tatproperty,or my employees Inwithwages r their sole C c &c.7044pereation,wllldothewormfr.Imk and the structures not Umnjmd(or - 5 0 ale(Sec.7044,to ainessendf property Code:The or Improves Weenie law docs f$ who does apply tornowner orp rough who Wilds mpoyed,povided cotsuch OCC.GROUP RES UNITS wprove ets amwork tinthimself dedorwgh hlsownemp,heave,er,the uildin or improvement issold intendeeyearofcomplroffered sale.theowevep t1der ill have .TOT •�- Improvement6soldwithin.neynaro(completion,lheowner-bu0derw111 have 1len of proving that hedid out build or Improve for purpose orale.). QTY; PLUMBING PERMIT FEE FLOOD ZONE APN as PERMIT ISSUANCE owner of the property,am exclusively contracting wllh licensed ore to construct the project(Sec.7044,Business and Professions Code: I The Contractor's License law don no not apply to an owner of property who ALTER-DRAIN kVENT-WA1112(EA) sw Wilds or Improves thereon, and who contracts,for such pRoject,with a FEE SUMMARY cgg(�ctor(s)licensed.pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE IJ I am exempt under Sec. B k P C for this reamn ' Owner Uate /�.Ly DRAINS hi00R ROOF,AREA,COND. l �. SANITARY Y N FEES OMPIN IONDECLA I - RECEBTM ` P of reby affirm that that I have a nrtiRnte of consent to sslf-insurs,or FIXTURES PER TRAP SCHOOL TAX Y_ N_ S cenifimtoofworken'Compe.ti nireuranceoracertifL,dmpythereof(Sec. RECEIPTp 3800,Lab C.) GAEA.5YSTEM-1 INCAOUTLET5 PARK FIE Y N_ Pollry p - GAS EA.SYSTEM-OVER 4(PA) RECEIPT p - Com any - B U I L DING DI VI SION FRES' Certified copy le hereby Nrnle city GREASEANDUSML WASTE INTERCEPTOR PLANCHECK FEE ' Crallied copy is filedhere y hirele city inspection division. JVD CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID L• COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.2BIFT. Date Remi tat Rhb section need nn W completed the permit 6Nr.ne hure ndd dollars (9100).rlsss3 WATER Ii EATER W/VENT/ELECTR ENERGY FEE Y N I certify that In the perfnrmince.f the work forwhich this permit is hated, — I shall not employ any person In any manner m as to become subject to the WATER 5Y5777d/TRFAI7NG Worker'Compensation l wa.f California. Data PAID C) Z Applleant NEWRESTDENTTALPLMB. SQFT. Date Recei tk Z 'NOTICE TO APPLICANT:ILafter making this Certificate of Faempllon,you ' should become subject in the Workers'Compereation proelalone of the LaborCC 'TOTAL' 4A Code,you Mgt forthwith comply with such provisions or this permit shall be BUILDING •E W > - deemed revoked. CL 3 - CONSTRUCTION LENDING AGENCY SEISMIC FEE cih I hereby arfirmthal there is a mastruction lending agency for the perform- ELECTRIC L) Z ance ofthe.rkf.rwhichthrspermltisWued(Sec.W97,Civ.C.) T U O I.noses Names PLUMBING FEE LL F Isndere Addrtss QTY. MECHANICAL PERMIT- FEEMECHANICAL FEE O W I cenlrythatl have read thlsappllcationand slatethattheabovainrormmion - Ismrred.Iagmeto comply'wlth all city and countyordlnancesand stale laws PERMI'TISSUANCE FEES PAID: } U) relating tobulldingnslruction,and herebyauthmire reprenta setivesofthb H 2 mcity to enter upon the above,mentloned property for lrapection purposes. ALTER OR ADD TO MFCH. Date Reeel IH _ (We)agree to save,Indemnify an d keep harmless the City of Cupertino - F a gal rut llabilltles,judgments,matsand expenses which nay in anyway accrue AIRHANDLINGUNITQOI0,000CFM) SUBTOTAL: agaln<t said City In m..equenn th antlegofthb It .. AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX .Ig !,m.f Applran/Cont, or Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: ' I. HAZARDOUS MATERIALS DISCLOSURE Illthe applicant.,future Wilding oocvpant store or handle hazard... HEATING UNIT(10100,000 BTU) Date Receipt r oarrial as defined by the Cupertino Municipal Code,Chapter 9.1Z and the Ilealthand Safety C.de Sedi..25532(a)7 !TEASING UNIT(OVER 100,000 BTU - TOTA ❑tYea No ' Willtheeppliont or No buRding ompanl use equiprrcnt or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE which doll hazardous air contaminants as defined by the Bay Area Air - - Pi A 10 I Quality Management DlsMNY. P BOILER-COMP pId'DR 1W,IXq BTU V 4 Yes No )witomia lhehrm o"C.dr,S ri.m2rnenleunder Chapter 6.95 of BORER-COMP(OVER]W,000 BTU) PR 28 1992 the Glifornlahealth building a tenant, that. 1 d�rJ� resprstandthat lithe notify thldingdoee of te correctlyhavewhich that 111 my NEW RESIDENTIAL M4ECli. EQ.T•7 . ( rssp.to Issuanclity of aCeheoate Of Ocr panty.requirements which must be rrM CI7Ir ser `u�' prior to Issuance ofaCertlfkate ofOmpanry. '` 4p_y�/� LirYyIIVV Ownermaulhorized agent Date ISSUED _ e- .^. TOTAL: OFFICE COPY