23071 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Preterit Identification PERMITNO.
Building Address:
23071
o s-8 Yn/I
wnereameNN V4 /C(J one:
(����s CITY OF CUPERTINO-BUILDING DIVISION '
C tr oz's a •�� a LIc.No: APPLICATION if PERMIT CC
� BUILDINGELECTMCALPLUMBING-MECHAMCAL CATEGORY CONTROL X
ArcMted/Engineer. Lk.No: - r
Q ELECTRIC PERMIT rFEE BUILDING PERMIT INFO
Address gIgrL_
(J¢. . PERMBTISSUANCE 'I]•OD
LI ENSED CONTRACTOR'S DECLARATION -
I hereby affirm that l am licensed under provisions of Chapter 9(commen APPUANCESRF.SIDENTIAL JOB DPSCRD'rION
ingwith Sedion 7DBO)of Dlvlkun3ofthe BudnessandProfmoionsCode,and my
license is in feu and effect / PANELS
LicenseCh LI,44E��( 1 s--•��
Date Contractor esA
RCHITECI' R 1TiON 1 TVLGI AMPS
�2 mind my pia hall publlcrecords. OVER3000AMPS SQ.Fr.FLOORARFA S/SQ.FT.
�qq�uu ° ' - ALED i
E��j Lim and Profenlanal SIGNS ELECTRICAL
6 OWN. •BUILDER DECLARATION SPLCULCRCUIT/MLSC ,- p /� U T E
7 owingrI hereby afRrmthaton7031 ,Balept theGalrfessio sCode:ense Law for M P 1
Q muntwhichrquireda pernito osumeaand Pimprove, Code:Anydtyor �V�
021=. TEMP.MEHR OR POLE INST. /^
F countruct en requires permute,consumer,alter, to '
ea`� any atrodod statement
that he is lleoregW pursuant to the
roomseersuch s;ofpermit e �Wq-g'D -' RA
file a signed palement that he V Ilansed pursuant to the provlelom of the Vf�
°µ TE
Contredorb License Law(Chapter 9(commencingwith Sed1on7000)ofDivi.3�O S SWAIM9NG POOL ELECFRIC
♦, the hasfthe the
Profption. Any violat ation
of exempt therefrom and VALUATION
the basis for the alleged exemption. Any vloln civil
of Section 70115 re any I OUTLETS-SWITCHES-FIXTURES r
Kl665 app0andred fora perMt$500),is the applicant loo dull penalty elect mom than
five hundred dollars(550 ,
(y A NEW RESIDENTIAL ELECTR SQ,FT. - STORIES TYPE CONSTRUCTION
0.•N2 ❑I,as owner of the property,or he employees with wages r their
resole
7d for
a mm(Sec.7044,wDldolherul Pmnsslom,rudurebnollntended oraff Law -
p sale(Sec.apply
B xri ow and f property
rope ty Code:The or imp eves Wmrue Law
�$ don notappty torn owner offprough hisom ilds employees,
improovided tatand OCC.GROUP RES UNITS
who
ovementswork tInten edoor rough hlsowne.If,hoes,p ,the build
Ing r ,
improvements am lnlendpeyeaifcompr offered rsafe.theo veptgderwdI have TOTAL: (tfl .
Improvement lswld withlnoneyea'io(compldlon,theowner•bugderwlll have -
Ihp-40rdeno1proving that he did mol build or Improve for purpose clads). QTy. PLUMBING PERMITFEE dPLODD ZONE APN
uu L as owner of the property,am exclusively contracting with licensed
cono-aors to deemed the project 70K Business aM Prefenbv Cade: PERMR]SSUANCE
The Contractors License Law don nor apply to an owner of property who ALTERDRAIN&VENT•WATER(EA)
Wilds or Improves thereon, and who co -
contracts for such p(ojects with e - ,FEE SUMMARY
mpj(ador(e)licensed pursuant to the ContradorL License law. BACX PLOW PROTFiC7.DEVICE
I_l l am exempt under Sec. B&P C for this reawn
OUTS I DE FEES
DRAINS-FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RFY.EII'I'tl
WORKMAN COMPaT45ATION DECLARATION p-IXTUgpS PER TRAP SCHOOLTAX Y N
❑I hereby affirm that I have o lrou ate of consent m opy chemo ora RECEIVr N
cenlflLab C(Workeri Comperaatlonlwurance oracertified copy t6erco((Sec. GAS EA.SYSTEM-]INCA OUTLETS PARK FEF. Y N
3800,lab C.)
Polity N RECGAS EA.SYSTEM OVER 4 MA) DING DI M
m any BUILDING DIVISION ISION FECS
Certified copy In hereby with
the city GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy V filed with the city lupe<ion division.
CCRTIHCATB OF EXEMPTION FROM WORKERS' GRILASETRAP i PAID
COMPENSATION INSURANCE
(Thissedlonneed not becomSEWER SANITARY-
pleted lithe permit islorom hundreddollan STORM EA.20OFr. Date Receipt#
(f]1mitify that
WATER HEATER W/VENT/fLECTR ENERGYFE•E Y N
[certify thatoy an person in
any Brunhe mk so as to which
pesubodrmit is to thend, ,
♦ I shall not employ any person in any manner w as to become aubjed to the WATER SYSTEM/TREATING
' Worken'Compewtlon Laws o(Ca11(ornla.Date PAID .
C• Z' Applicant ' NEW RESIDENTIAL PLMB.__SQ.Ff.. Date Recei t#
Z O NOTICE TO APPLICANT:If,after nuking thin Certlflale of Exemp[lon,you _
should become subject to the Workers'Compensation Prov,.Ite=Labor - - TOTAL:
N Code,you must forthwith comply with such provinions or this permit shat)be BU E•
W 9 deemed revoked. _
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE.
Z Iherebya(flrmthat thea is a mratructlon lending agency for the perform, - TOTAL ELECTRIC FEE .B
ance of the work forwhich this permit is Issued(Sec.3097,Cia.C.)
V O lenders Name - PLUMBING FEE
IL Iender.Address QTY.I MECHANICAL PERMIT FEE MECHANICAL FEE.
OW Icedifythat l have mad this applicatlonand Information date thattheabove infoation
1 ucorme.I agree to comply with all diyand county ordinances and gate laws PERMIT ISSUANCE FEES PAID:,
} N relating to building construction,an hcmbyaulhod@a mprearntativn.ofthi.
,F Z city to enter upon the above�crxmlo property for inspection Purposed. ALTER OR ADD TO MECH, Date Reeei t#
_ (We)agree to save,Indemnify a d keep harming;the City of Cupertino p
agalmthalllltienjudg ts,mksan expepanwAichmaymanywayacaee AIR HANDLING UNIT(O 10,000CPM) SUBTOTAL:
old City m ton gran ng of this pertnit.
era AIR HANDLING UNIT(OVER 1o,000cPMi) CONSTRUCTION TAX
Si alum.!AppIi C tractor, it I - Date EXHAUST HOOD(4V/DUCT) - CONSTRUCTION TAX PAID: ,
HAZAR OUSM ERIALS DISCLOSURE
WIIltheapplianl orfi um build agorsmpantstoreorhandlehansuckus BEATING UNIT CTO IOD,ODO BTU) Date Recei f#
matertalaadefined bl'the 'p' urldpsICod,Ch.ptd9.IZ..dthe
Hc❑lt Y�d Safety, ade,_SMloon 755 2(a)? HEATING UNIT(OVER 100,000 BTI!) TOTAL:
Will the applicant orfutum building occupant use equipment or devices NFN'DLATION FAN(SINGLE RE-SID) ISSUANCE DATE
which emit hazardous air conlaminents as defined by the Day Arca Air - U1 Ry ;p �'
Quality Management District? BOILER-COMPpHPOR100,DN,BT T Ai
4Yn ❑❑No
have mad the hazardsusmaterials requirements under Chapter 6.95 of B01LER{OMP(OVIR iW000 B'Hn- DEC —_.51991
the Celifernla Health&SafetyCade,Stolons 25505,25S33 and 25534.1 d.
understand that if the building does not currently have.tenant,that it b my NEW RESIDENTIAL MECH SQ.Fr.. ;t ,.
mspoeslblilty to notify the occupant of the requirements which must be met
Price to Lanus nee of a Certificate of Om pa ncy. CIII t)E 140ft iI IIVU
Owner or authorised agent Data ISSUED BY-
TOTAL:
OFFICE COPY