23055 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Address: 23055
CC A �A
Mre ante: hone: A A ATr
x t' / p f f t--I 'GJ' CITY OF CUPERTINO-BUILDING DIVISION
enact ..Name: Lic.No: APPLICATION / PERMIT
L BUILDING-ELFOTRICALPLUNTBING-MEOH MCAL CATEGORY CONTROL X
'A Itea/Engineer. Lk.Na:
QTY- - ELECTRICPERMIT FEE BUILDING PERMITINFO
Add. PFRMITISSUANCE '�I
LICENSED CONTRACTOR'S DECLARATION L�j LdCJ
I hereby affirm that l amlicmaed under prowuleirsof Chapter9(commere APPUANCESRESIDENTIAL ESCRU'DON
ingwithse on7OUD)of Dlvlsion3ofthe Businmand PrefessionsCode,and my
license b In full form and dfect, PANELS
License Clam Lie X A?•LL �P
Date Contractor
ARCHITECTS DECLARATION 201'1000 AMTS
1w, ]ued co
nderstand my plans shall beusa public records. OVERIDUOAMPS SQ.FT.FLOOR AREA F/EQ.FT.
i Uu Licensed ProfessionalSIGNS ELECTRICAL q L.E D i
=¢� OWNER-BOLDER DECLARATION SPECIAL CfRCIRT/MLSC M p U T E
,4� owing ature.(that lam31.5,B(romthe Contractor's License Law fort he
=nty hichmqu6 apeion? tS,Business and Pmpmese=d hycityor TEMP.METER OR POLE INST.
munrycture requlrva pemdem alsoreq,alter,implbcant erro0ah,ornpalr /
� < my aVumnrt statement
that
he Is alsouad pursuantrinathe p the pro uch isdoes of t e POWER DEVICES //��
V file a signed statement that he t r 9(sued pursuant to the Provisions of the
Cantnctors License Law(Chapter9(mrunenong with Section 7000)o(Divl- SWIMMING POOL ELECTRIC
ion tlon3cfdaBudnmmd Profmlaru Code)orthehebemmptthemfmmand ^ VALUATION M
5 the bub for the alleged exemption. My violation of Section 70315 by any OUTLETSSWITCHESFIXTURES �r 1 1 i
applicant permit the appUunt too civil penalty month
an
.(ratn 1. `� Vim^
o_ five hundred dolls.($500.
NEW RESIDENTIAL ELECTR SQFT. STORIES TYPE CONSTRUCTION
I,as owner of the Property,or my employees with wages a their sole
Viz. cognparsaft.,will do the work and the structure b not intended or offered for
= p sale(Sec.7064,Buslnev and Profm)ons Code:The Contractor.License Law
3$ donot apply to an owner of property who Wilda or improves thereon,and OCC.
n GROUP RES.[TMTS
who does such work himself urthrough his own employees,provided that such
improvements are not intended mothered for sale.If,however,the Wilding or TO
V.
Improvement bsold within one yearafcomplcion,the owner-WBderwill have - ,
rden of proving thathe did not build or improve for purpose of ale.). &Y. .j' ,�, PLUMBINGIPERMIT ). ' FEE'
tl�u - FLOOD ZONE APN
L_j L as owner of the property,am exclusively contracting with Hormad PIRMUISSUANCE
mnmaon to wee vua tk project(Sec 7064,Businm and Profmlons Code:
The Contnmr'a License Law don not apply tom owner of property who ALTER-DRAIN&VENT-WATER(EA)Wilda or improvesrsm theon,and who conmafor so& pzueets with a _ '
�gpTdor(s)hennaed pursuant m the Conmaace's License Law. � ',�• FECSUMMARY,, -
Lf 1 am exempt under Sec 0 &P C for this noon BACKFLOW PROTECT.DEVICE
Owner Date DRAINS'FLOOR,ROOF,AREA,ODNID. SANITARY RECEIPT If
WORKMAN COMPENSATION DECLARATION F.IXTURES , SCHOOLTAX Y_ N_
pl hereby affirm that I have a ceMfiate of consent to aeR-Inane,oraPERTRARECEIPT X
mrtificateofWorken Compensabonlmuranm ora mrtUicd copythereof(See. GAS E.A.SYSTEM-1 INC4 OUTLETS PARKITTE Y N
MOO,PoileyLab 453 0RECEIPT ar
Cam n31bP--r��S�t�l l GAS EA.SYSCEM-0VER6(FA) BUILDING DIVISION FEES
6 CegNed copy Is her0by tumisn PLANCHECK FEE
CertUed copy b filed with the city inspection division. CREASE/INOUSfAL WASTE INTERCEPTOR
CERTIFICATE OF ID(EMPTION MOM WORKERS' GREASE TRAP PAID
COMPENSATION:INSURANCESEN,FI-SANITARY-STORM E.A.21101' Date Recei tN
(This section need net be completed R the permit is for one hundred dollars
(S1UNm
ori .) WATERITEATERW/VENT/ELECTR ENERGY FEE Y_ N_
I mrt0y that in the performance of thework forwhich this permit is issued,
1 sha0 nm employ any person In any manner m as m become subject to the WATER SYSTEM/TRFATING
Workers Compensation Laws of Califomia.Date PAID
Applicant Date Remi tic
Z O NEW RESIDENTIAL PLMO. SQ.FT.
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
• shmld become aubpet to the Workers'Compression provbbns of the Labor TOTAL:
N
Code,you=at forthwith comply with such provisiom or this Forgot shall be BUILDING FEE
> deemed revoked.
G CONSTRUCTION LENDING AGENCY SEISMIC FEE t
I hereby af0rmthat there b a comhuetlon lending agency for the perform- TOT ELECTRIC FEE
Z arm ofthe work for which this mat is Issued(Sec.3097,Civ.C3
) O I<ndar.Name PLUMBING FEE
I— Lenders Address QHA
TY. MECNICAL�PERMIT - FEE MECHANICALFEE
U I.AlfythatlhavereadthbapphmtionaedaatethattheaboveNfor tion A -� FEES PAID:
4 Boomer.LagaatocamplywithaUdtyandmuntyordmanmandaatelaws PERMIT ISSUANCE
N relating to building construction,and hereby authorize representatives of this
city to emerupon the above-mentionsA property for Wpm1m,purposes. ALTER OR ADDTO MECH. Date Receipt#
Z
Z (We)agree to save,4rdemrdty an d keep harmless the City of Cu peAtno AIR HANDLING[IMT'(TO 10,=CFM) SUBTOTAL:
against liabilities,pdgments,miss and expenses which may m m
anywayaue
taidagainst Try
m sequence oAIR HANDLING f the granting of this permit. CONSTRUCTION THANDLING UNIT(OVER 10,W0 CFM)
Sgmtunof AppU n[ antra or Date EKI-wUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIA SDISCLOSURE
Will the appUant or future building occupant store or handle havrdous 7-IF-ATINGUMT(TO100,000BTU) Date Reeel IN
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(aP HEATING UNIT(OVER IMBED BTU) TOT
Yea MNo VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
WIII the nd rat or future Wilding occupant use equipment or devices
which enham
at hardoua air contaminants as defined by the Day Arca Air
Anality Managcrrnt DisWctt BOILER-COMPpFU'OR 100,0(0 BTU)
Yee, No
havereadthe Fav esu materials requirements under Chapter 6.93 of BOILFR-COMP(OVER 100,000 BN) p•
the Gltand t at if thealthe
&buildafetying
Cods St•aions currently
a3 and tenant,that. I [a
understand that it the Wilding don net mrtently haveatenant,that ltbmy NEW RESIDENTIAL MECH. SQ.FT
responsibility to notify the occupant of the mquinments which must be mot
prior to issuance of a Certificate of Occupancy. DEC _G • 2 1997
Owner or authorired agent Wit, TOTA ISSUED',ByY:
YV
OFFICE COPY