23536APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —'USE BALL POINT PEN ONLY
-Building PraiserIdentification PELMITNO.
Building Addre
ss:
ZDS 6 i<IfzwlN LANG C��E2i(No '
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23536
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDINCEAFCTRICAL-PLUMBINC-MECHANICAL
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Cortactor's N.me: LIc. Nu:
IME(, OLS L Q,
CATEGORY - CONTROL
BUILDING PERMPT'INFO .•
Archllect/Englnesr.LI No:
JS WAE 'EM&VI.I - ZS
QTY ELECTRIC PERMIT FEE
Addrcvs /p Stx IJAI.FI- WIT) O
I'ERWTISSUANCE -
♦
LICENSEO CONTRACTOR'S DECLARATION
Thereby. afflrmthatlam Ucrosedunderprov ionsof Chapter9(com mc-
ingwlth Semon7OUO)of DiviMm3ofthe Bustrmsaand ProfealoesCods, and my
license le In full fareeand affect.
License Clans Lica ZZO i3Z
Data 3 Contractor — 0(�.$
APPLIANCMRESIDENIAL
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✓'['u��It—: a0L
PANELS
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701-1000 I'S a
t ARCHITECTS DECLARATION
I understand my plant shall be used a publicremrds.
OVER1
AMPS
.FT. FLOOR AREA
5/SQ.Ff.
SIGNS EL TRIC
Licensed Professional
/. o a i?
OWNER -BUILDER DECLARATION
I hereby affiumthat I am exempt from the Contractor. License Law for the
followingreaon.(5ced.70315, Bueinesaand Profeselons Code:Anydty or
awntywhichmquie aperrNttommtmd,aller,improve,demlbh,ormpalr
anysuumere pdortolle i uance,also requlreatheappUcent for such permit to
file a signed statement that he,b licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9 (commencing with Section 7000) of Div)-
the 3 ofbasis for of exempt therefrom and
the bean (or the alleged exemption. Any violation o(SMlon 7etm by any
the allege and Professions Any vioode) or laat tion
applicant apems subjects the applicant loa civil penalty o(natrrorcthan
SPECIALCIRCUI
9
TEMP ME[ER OR
POWER DE'ICFS .
' SWIMMINGPOOLELECTRIC
_
OLTMIT SSWITCHESFIXTURFS
VALUA'DOi
/Qt9 fid ,
NEW RESIDENTIAL ELEG SQ.I•T.
five 1, as .o of the W).
QlS
1, as owner of the property, or my employees with wages as (heir axle
SR7WE
TYPE CONSTRUCTION
compensation, wilt do the work and the structure is not Intended or offered for
.In (Sec. 7094, Dust., and Profealona Code: The Contractors License Law
does nolapply to an owner of property who builds or improves thereon,and
who domauchwork himal(orthrough hlsownerepieyea, provided thatsuch
OCC. CROUP
RFS.I/N[[S
improvements are not Intended urof(ered forale. 11,howevegthebullellegor
improvement lawld withinomyearofcompleion,theowner-builderwill have
tll!yLden ofpmving that he did not build or Improve for purpose ofsat
LI 4 asowner of the propeity, am exclusively contracting with Ileamad
contractor to mrumeet the project (Sec. 7019, Businea and ProtealonsCode:
T
QTY, PLUMBING PERMIT, FEE
PERMIT ISSUANCE
_
FLOOD ZONE
APN'
'Die Contactors Llcetue Law does not apply to an owner of property who
Wilds or Improves thereon, and who contrafor such pipjacs with a
coLactor(s) Ilcenxd pursuant to the Contractor. License Law.
I am exempt under Sec. B & P C for this reasonOUTSIDE
-
ALTER -DRAIN & VENT - WATER (EA)
- FEE SUMMARY
BACK FLOW PROTECT DEVICE
r
RAINS-FLOG ROOF,
R AREA, GOND.
SANITARY Y_ N_•
BBC= as
Owner. Date
WORKMAN COMPENSATION DECLARATION,
mI hereby afilrm that 1 have
Y_ N_
a ceni0ate of consent to uB-0dgdm, or a�5�TRAPSCHOOL•1'AX
conflate ofWorkers' Compensation leeurince me certlf4d copythmeo((Sec.RFGEfP[a3800,IebC.)
AS EA.SYS EM-11NC,1 EI5PARK
FFP Y_ Nom
AS-EA.SYSTEM-OVER )
IF
any
BUILDINGIVIg10N FEE5
Candied copy is hereby fumlehed.CertPed copy Js (IlM with the dly//lV[pMion divldoa
REASE/INDU LW •INTERC R
PLANCI-IECKFEE
CERTI/ GTE OF EXEMPIiON FROM WORKERS'
INSURANCE([hisseman need not be completed if the permit is forone hundred dollarsggWrEg
PAIDCOMPENBATION
Date RC
REASE TRAP
-SANITARY -S[ORM
ATER HEATER W/VENT/PIECTR
ENERGY PEE Y
'r 20
PAID _?V
(E100)m1e.sJ
1 certify that in the performance of the work forwhich this permit Is lowed,isa
label]not employ any pe. In any manner w a to become wbject to the
Workers Compensation Lawsof California. Date
W,A.� s,��/TREATING •^
Applicant
NOTICE TOAPPLICANT; e afterrds'C. fhb tledlpre of Exemption,You
should de,you me subject it the Workers' Compewtlonpmvbiaarmit of s Lab be
et forthwith comply with each proal (onsonhh permit shall be
deemed revoked.
dermad revoked.
NEW RESIDENTIAL It SQ.T.
Date Recei t#
'I'
BUILDING FE ��
CONSTRUCTION LENDING AGENCY
I hereby affirm that there b a matruction lending agency for the perform
ance of the work for which this permit is Issued (Sec. 3097, CIv.CJ'
SEISMIC FEE
ELECTRIC FEE
Lender's Name
Lenders Add.
I mrti(ythat I have read this application and statelhatthe above Information
Is corms. l agreeto comply with all Aly and county ordinances and state lawn
QTY. MECHANICAL PERMIT FEE
PERMITISSUANCE
PLUMBING FEE
MECHANICAL FEG ��
FEES PAID: ,
relating tobuilding construction, and hereby authorize eapreantativea of this
city to enter upon the above-mentioned property fee Inspection purposes.
(We) agree to save, Indemnify and keep harmless; the City of Cupertino
against liabilities, judgments, mstsand expenses rahlch may In anyway accrue
against aid City In consequence of the granting adds permit.
ALTER OR ADDTO MECH.
AIRHANDLINCUNrr([070,W0CFM)
Date RCCCI t#
SUBTOTAL:
AIR HANDUNG UNIT (OVER 10,000CFM)
CONSTRUCTION TAX
Sig®lure of Appilanl/Contactor Date
HAZA R DOES MATERIALS DI S('LOSURE
FXHAUSTIIOOD(W/DI1C73
1
CONSTRUCTION TAX -PAID:
` HEATING UNIT (TO 100,000 BTU)
Will the a ppllont orfulure building omupapt store or hand Is hazamous
material as defined by the Cupertino Municipal Code, Chapter 9.1 7, and the
Date RCCel
-j HEATING UNIT (OVER 100,000 BTU),
IOTA .
Ilralth add Safety Code Section 75537(.)7
Yea M No :-
VENTILATION FAN SINGLE RESID)
ISSUANCE DATE'
Will the applicant orhimm building occupant use equipment or devise
which emit hazardous air contamimnts as defined by the Bay Area Air
NOBLER -COMP OHP OR 10(1,000 BTU)
Quality Maragemant Dbtrict7
4 Yasl.ead the havrofZ1 No
have us materials requireene 4. under Chapter 6.95 of
the Calltomla Health & Safety Code, Sections 25505, 75533 and 75539. I
® -�(',•
j
- •(
BOILER-COMP(OVER 100,000 BTU)'
N RESIDEMIALMECLL SQ.pr.
understand that if the building dues not currently have a tenant, that It is my
raponsibllitym nojjy theoccupanteof the oupanequlmmentswhich must be mM
prior to tau nce Cer/lflcateopmpanry.
MAR 3D. 199a�t(7�,
a t 3 z3 5
^'I . $ Ir t*
Owners thodred agent Date
-
�T
ISSIIEEW.
OFFICE COPY