23128 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
• Building Pm'ed Identification PERMIT NO.
B°°ding Address;
2312$
2 -tet+ PSA
1 eares: one:
:j6 �� �3 CITY OF CUPERTINO-BUILDING DIVISION
Contmdors Name: Lic.No, APPLICATION / PERMIT l
BUILDINGELECTRICALMUMBING-MECFAMCAL CATEGORY CONTROL N
Architect/Eaginmr. Lie.Nn:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO .
Address: PERMITISSUANCE 50
by LICENSEDCONTRACTOR'SDECLARATIONco mon
IheredtioxnrmthefDivsionsedhe Busiessandprefeagoer9ds,and e- AI'PLIANCFSRESiDENIAl JOB
11 reseh Sect ion force ofd effect.
ofthe Buelriessand Pro(euioneCodn,and my
Liodesln full farm and dfect. ^ - PANELS
License Class LICK
Date Contractor
ARCHITECTS DECLARATION 7SIGNSELB�CALI
MPS
q�q�++++Q C77 I understand my plans shall be used as public records. . 7.FLOOR AREA $/9Q-FT.
k u Limned Professional - _6OWNEWBUILUER DECLARATION BiC T Mt Iherebyaf@m thatI am exemptfrom the Contractor's License lawfmthe og following mason.(Scdion 7031S,Business and Professions Code:Any dtyor EBOR L
F �' countywhkh requiresa permitroconslnd,alteq Improve,demolbh,orrepalr `
a
anystructure prbn
lorto its nnceb
,aorequlreatheapp0nt m (m such permit to
O�U file a signed statement that he b licensed pursuant to the provisions of the ROWER DEVICES
u, Contracted License Law(Chapler9(commencingwith Section 7000)of Divi- SWING POOL ELECTRIC
CVALUA71OLJS'
u�
SOS don3ofthe Buslnessand Profembv Code)mthat hale exempdhere(romand
the basis for the alleged exemption. Any violation of Section 7011.5 by any OUTLETS-SWITCHES �� /O O/4ila
GFapplicant fora permit subjectstheappliesoutoa civil penaltyofnol mom]has i �v��//
I
ndred dollars(g500). - NEWRESIDENTIALELECTR SQFI. STORIES , TYPE CONSTRUCTION
�n {{((I��I)���{,((uu as owner of the property,or my employees with wages as their wk _
c�penuHon,wiEdothe work andthe structure b nut Intended or offered for
D Ie(sec 7044,Buslnase and Professlons Code:The Contradors License Law
r3',$ does not apply to an owner of property who builds or Improve thereon,and
EEEE who does such work himselforlhrough his awn employees,provided that such OCC.CROUP RFS.UNITS
Improvements are not Intended oroffered for sets.If,hmvovegthebulldlagor T �.
improvementissold within oneyearofcompldiogtheowner-bu0derwlll have
tl�Jgvden of proving that he did not build or improve for purpose of sale.), QTY. 'PLUMBING PERMIT FEE FLOOD ZONE ApN
LJ I,as owner of the property,am exclusively=trading with llmnaed pp iT ISSl1ANCE
cont don to conatrud the project(Sec.7014,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(FA)
builds or Improves Ihemon, and who contraN contracts for such pipjewith a
Inporfs)licensed pursuant to the Contractors License Law. - FEE SUMMARY
amexempt under Sec B k P C for this reason BACK FLOW PRO'T'ECT,DEVICE
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY 'Y N_
Date RECEDxT N
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of consent'to self-insure,or a FIXIURCS PER TRAP �� SCHOOL TAX Y N
mrclflcate o(Worken'Co RECEIPT
mp<matlon Insurance ora certified copythemo((Sec.
3800,Lab C. GAS EA.SYS'fEM-]INC.4OUTLETS PARK FEE Y_ N_�
nry p CAS EA.SYSTEM-OVER 4(EA) RECEIPT N
CoCm any - BUILDING D I VI SION FE IS
Certified copy Is filed with tthe city GREASE/INDUSIRI.WASTE INTERCEPTOR. PLANCHECK FEE
Certified copy b filed with the city Inspection division.
CCRTIHCATEOP EXEMPTION FROM WORKERS' GREASETRAP, PAID
!
Cot barn
COMPENSATION INSURANCE SEWER-SANITARY-STORM RA.20017. Date Recei tN
TTM or I..) need not be complMed I(lhe permit b(orcare hundred declare
(E100)otifyth WATER HEATER W/VENT/Fd.CC'IR ENERGYFEE Y _ N
all not that N(any pehe orrn In an the nnerwork wr s tobedb permit h issued,
I ork not employ any parson In any manner so s to become subject to the WATER SYSTEM/.TREATING
Workers'Compcnution laws of California. Date PAID
O Z Applicant NE'WRESIDENIALPLMB.' SQ.FT. Date Recei IN
Z N0710E TO AI'PLICANI:IQ ager reeking slab CcrtlfF teof Exemption,you
should become subject to the Workers'Compensation provisions of the Labor - ,TOTAL: _
N Code,you at fort hwlth comply with such provhlom or this permit shall he 1BU `N
W > deemed'revoked. - FEE
D. C CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hemby affirm that there b a construction lending agency for the perform ELECTRIC FEE
M Z anceofthework(urwhlchthb permit b blued(Sec3097,Civ.C.) - T _—
V O lender.Name PLUMBING FEE
LL F Lender's Address QTY. MECHANICAL PERMIT FTE MECHANICAL FEE r
OW Icerclfythatlhavemadthbapphutlonand state that theabove Information ,,;..�
G [a correct.l agree to comply with all city and county ordinances and date laws t I'FRMII'ISSUANCE' FEES PAID:
'> or
to building construction,and hereby authorize representatives of this
Zcity to enter upon the abovcmationed property for inspection purposes. ALTERORADDTOMECH. DRIC ReCel t#
_ (We)agree to save,Indemnify an d keep harmless the Cityof Cupertino
against liabilities,judgments,"sand expenses which maylnanyw a AIR HANDLING UNIT TT010,000 CFM) SUBTOTAL:
a alnslu ityl encu o(the granyl o/(ng hie permit/ 20
AIR HANDLING 116iir(OVER lo,000cFhO CONSTRUCTION TAX
'Ignature of Applicant/Contractor ate ExHAus.r HOOD(W/DIJCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE -
Willtheapplicantorfuturebuildingmcupant.tore or handle hazardous HEATING UNIT(TO 100,000 BTU) DRIC Recel IN '
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the - -
Health and Safety Code Sectlon25532(a)7 HFATING UNIT(OVER 100,000 BTU) - TOTA
❑ Yes Ne
Will the applicant or tore building oczupant use equipment ordevices VFNILATIONIFAN(SINGLE RESID) ISSUANCE DATE
which ends hazardous air contamioanm as defined by the Bay Arca Alr
Quality Mawgcmeat Distrid7 BOILER-COMP OHP OR 100,OM BTU)
4Yes I�INo
hacereadthchz`fouematedalamqulrenenhunderChaper6.95a! BOLGR-COMP(OVER100,000BTU
the California Health&Safety Code,Sections 25505,25533 and 25534.1 DEC .1991
understand that if the building does not currently have a tenant,that 11 bmy NEWRFSIDENTIALMECH. SQ.FT. GLH/ 1a7s7
responsibility to notify the ocasp rA of the requirements which must be met
prior to Issuance of a Certificate Of Occupamy.
CI I Y est CUrc I v
Owner or authorized agent Date �}.
TOT ISSUEDO
OFFICE COPY