23619 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES = USE BALL POINT PEN ONLY
Building Pro'et identification - PERMIT NO.
Building Address:
23619
toy 0 l.oaaA La,Js%
ser ante: e: A
sQ �( . Gkt�-0Y 2S-t�YfCITYOFCUPERTINO-BU#[.DI IVISION
°nuador.Nem: Lic.NO: APPLICATION / RMIT S
A itet/En neer BUILDINGELECMCA4 O-MECHA AL RV CONTROL a�
``,,''/ C7iQ+92 QTY ELE PERMIT BUILDING PERMIT INFO
Address:1�5 I KLS� /d•r/ 17
PERMITISSU �-
LICENSEDCONTRACTOR'S DF.CIA ATION
Ihereby affirm that l am licensed under provisions o(Chapter9(mmorenc- RESIDENITA - JOB DESCRIPTIONIngwith Setion7000)of Divielon3ofthe Bu.ireaand ProfeWansCode,andmy -
li...1.1.follorce and effect.
Lcen CoMntor A4�'
ARCHITECPSDECLA ION 1-10D0AM
XZ I understand my plans shall be used as public records OVERT" SQ.FT.FLOOR AR S/SQ.FT.
obCO ,gyp
Z(/ Licensed Professional SIGNS EIEC CAL &'Z,?O
IM • OWNER-BUILDER DECLARATION 1ALCIRCUIT LSC
ZI' owingraf(Irm561.o731.5,Business fmmihe Contractor's License law forthe
or '�O
following raaaun.(Section 7 tomt and Professions Code: h, t or CC 1`JTIjYr �`
F Icp
"'t9i countywhkh rcqulreea peroutto mrutvct,alter,lmprove,dertnWh,arrepalr TFMP.M RPOLE INST.
anystmetum prlorto its Issuance,also requlrestheappllant for pe he
O file a signed statement the he V Ilcenad pursuant to the provls,0-°f the POWERACES ZQ 3
µ1l-� Contnim.License lsw(Chapter 9(mmnenWgwith SMbn7000)ofDivl-
�OJ cion3 ofthe Business and PrefmbmCode)orthe he isexempt therefromand NG POOL ELECTRIC VALUATION
S°•33 the basis for the alleged exemption. Any violation of Section 7051.5 by an s /�
eppUant fora permit subjects the applicant to a civil penalty ca moretlun O ETSSWITCHESHJ(TURES /J y(
Ove hundred dollenhepr. NEWRERDEN77ALELECTR SQ.FT. STORIES •7 TYPE CONSTRUE:ION
�n
MI,asowarll theproperty,or my employees withwags atheir sok
rompenatlon,wllldothe work and the structure V not Intended or offend for
q ale(Sec.70K Business and Profmioro Code:The Contractors License Law I N A L IC
3$ does not apply to an owner of property who builds or improves thereon,and G
who doessuch work himself orthrsugh Msown employees,provided that such
Improvements are not intended°roffered for ale.If,however,the building or Ti
TR
Improvement la sold within oneyearofcomple ce,the owner-huBderwlll have
t rden of
proving that he did not build or improve for purpose ofale.). QTY, PLUMBING PERMIT FEE p7p
L as owner of the property,am exclusively with licensed
mntncton to mmmid the projet(Sm 70K Businessand Profmiors Code: PERMIT ISSUANCE
The C°ntntors License Lawdoes not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such pt°Je to with a ALTER-DRAIN Ek VENT-WATER(EA) �.
B[lao
&or(.)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT,DEVICE FEE SUMMARY
LI I aclm
exempt under Sec. B k P C for this monOUTSI DE FEE S
Owner Date DRAINS A,FLOOR ROOF,ARECONTE. SANITARY Y N
RECEIPT M
WORKMAN COMPENSATION DECLARATION
pl hereby affirm that I have a amflaFIX'IURF.S PER TRAP �_ SCIdOOL TA% Y N
te of consent to self-Insure,or RECEIPT M
cerclRate of Worken'Compersatlon Insurance or a aeiBed copythereof(Sec.
3800,Lab C.) GAS F.A.SYSTT
EM.1 INC4 OUTLET �,� PARK FEE Y_ N_
Policy M GAS EA.SYSTEM-OVER 4(UA) RECEIVE M
Com any BUILDING DIVISION FEE
�Certlfled ropy is herebyth the ed
city CRRASR/WDUSTRL WASTE INTERCEPTOR PLANCHECKFEE 327`f
�CedifI it copy is filedh.n with the tlty ire)ectlon division.
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM UA.200Ff. Date Revel tN
f0)or lion need nu W completed Kt1e permit bforoa hundred dollars
(51I0)orfy that
WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
Icertlfy that In the performance of the work forwhkhthls permit is hated,
I shall nli,craot emplo y penton In any manner so a t/be to the
�5pq� WATER SYSTEM/TREATING O
W Applicant Co Ion Law.nJ Glifor>Ia.➢ale '�'/'" PAID
O Z Appllant CeMe3f�GdL NEW RE9DENTUL PLMB. SQFT. Date RCCei tq
Z O NOTICETO APPLIC .H,altar saki gthlx .edBlate of Exemption,you
should become subject to the Worker'Compenation provbioa of the Labor TA : 7i
W Code,you must forthwith comply with such provisions or this permit shall be BUILDING .��
W 9 deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FE' 7x
a Iherebyaf0rm that there V a mmtmtion lending agency for the pedorm ELECT
Z ance of the work(or which Nb perMti.L+sued(Sec.3097,CIv.C.) - T /s
L) ]enders Name P M F' �►
LL F landere Addna QTY. MECHANICAL PERMIT FEE M WA196L L FEE
O W Iced agmetoc comply
with
aBcatlandc county
ordinances
and stateI on
C Urorret.7agrceto comply with all city muntyordinancn and elate laws PFRMRISSUANCE FEES
N relating to building construction,and hereby authorize representatives of this 113
(_ Z city to enter upon the above-mentioned properly for Impetlon purpose. ALTER OR ADD TO MUCH. ( ReCCipf#
(We)agree to ave,Indemnify an d keep harmless the City of Cupertino
V against liabilitb,PrIgments,coesand expenses which may lnanywayaccrue AIR HANDLING UNIT(T010,000 CFM) TOTAL'
sgaWt al Ity in commof the IF sting of this permit �.
AIRHANDUNGUNTEOVER l0,000CFM) G N X
Igwtvre of App&dht/Co.G%d.r Date LTCTIONTXPAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a ppllant orfuture building occupant afore or hand le hazardous HEATING UNIT(TO 100,000 BT" ate R el #
material as defined by the Cupertino Municipal Code,Chapter?.IZ and the -
Ilealth and Safety Code Section 25532(a)2 HEATING UNIT(OVER 100,000 BTU) T
❑Ye No
Will the applicant or uNre building oavpant use equipment or devices VENTILATION FAN(SINGLE RFSID) j59UAN�GE,DA'I'E
which rout hazardous air contamiants as defined by the Bay Area Air s �-.� - 'u
Quality Management Dlstrlt2BOILER-COMP OHP OR 100,000 BTU)
� FPI Yea ❑❑No
Thave read the hazaZorrztedals requirements under Chapter8.95 of BORER-OOMP(OVEft 100,000 BTU) Je pj
the California Health k Safety Code,Section 25505,25533 and 25534. 1
understand that if the building does not arrently have a tenant,that It is my NEW REM DENTIAL MECH. SQ.rr WI/
responsib111ty to notify the occupa nt of the requirements which must be met VI Y VV C
prior to Issuance of a CertlBate of Occupancy.
Owner or authmized agent Date ISSUED BY:
OFFICE COPY