23257 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PUI MIT NO.
Building Address: 23257
1041x( M��-k`c A CouP-k
t s one: A A A
JOEa IND"( �A2Rt�k-L- CITY OF CUPERTINO"BUILDING DIVISION -1,19
_1 �j�
•GantArol s Name: Lic.No: APPLICATION if PERMIT �"—I
I BL.7LDINGELECIRICAL-PLUMBINC MECHANICAL CATELORY CO:YIROL
A iter/Engdaer. Lie No: '
OOV�
=11F �ELECTRYC RMIT FEg BUILDING PERMITINFO
Adores S. PERMITISSUANCE
LICENSED CONTRACTOR'S DECI.IRATION
APPLIANCESRESI ENITAL
1 herebytion70that 1 Division
ofunderprovWonsof Chapter 9de,and c JOB DESCR}I'IIO(J
incense I,to full force of Dlvfect. fthe Businessand PmfnsionsCode,and my ^^ ^Xr'.,.N7}`�
license Class force and effect. PANELS
License Clan LIC#
Date Contractor
ARCHITECTB DECLARATION 1"
C�1+u2 i understand my plan shag n be used public recvnd> _ O AMPS SQ.FC.FLOOR AREA 5/SQ.FL.
0u� }^�
q 6 Licensed Plua
rofesnl
S SEL A
H TTT
w
U OWNER-BUILDER DECLARATION PECIAL /MLSC yyy
I hereby afBrmthat ram exempt fmmtheContrsdor'sLlmnse Lawforthe
?gF,� following mason.(Section 7mt.5,Business and Professions Code:Anydty or TEMP.M OR TOLE INST.
—y c°untywhichrequiresaper ttowmtmd,alter,impmve,de=o h,orrepalr
anystwchme priorto its Issuance,atorequdres the applicantfor such perMtto POWER
c U file a signed statement that he is licensed pursuant to the provisions of the
OSS
Contractor's License Law(Chapter 9(commencing with Section 7008 of Div l- SWIMMING ED0CELEUMC
3 Fn VALUATION
O thesiobasis for
the
ed exemption. Any orthatn of exempt therefrom and
Y m<� the basis for the alleged exemption. Any t tolaclo of Section no m by any ETSSWITCHESFIXTURES s�LV El I
-rep 'PPBcantfor a permit subject the app8canttoadvil penalty of no rrorethan
Ove hundred dollars MSM. t a� D ELECTR SQ.FT. STORIES TYPECON'SIRUCTION
.. 1,as owner of the property,or my employees w{aavxbe the
CZE compensation,wBl do the work and thestarureis not ten vr'af(` for
Cp sale(Sec 70K Bualnev and Pm(essloa Code:The Co dofrLire
Mj' don not apply to an owner of property who builds or pmvp th� r—V I OCC.GROUP RFS.WITS
c whodceasuchwark himse8orthrwgh hisownemploye rovlded thatsuch
Improvement are nm handed orot(ered(w sale.IL however,thebuildtgw TTI �F
o � + athAj;urden of proving that he did tort build or lmpmve for pwposeof sa .. QIY PLUMBING ERMIT Flppp]ENE APNLI L as owner of the property,am exclusively contracting with licensed ' PERMIT ISSUANCE
contractors to wrutruct the pmjed(Sec 70K Business and ProfesbruCode:
The Contractor'.License law does not apply to sm owner of property whoALTER-DRAIN 4 VENT-WATER(FA)
build.or Improves there
on, and who contracts for such pipjecn with a T -St
c L�
,�IlLLtTTactor(s)Banned pursuantm
to the Contractor's Llcee Law. BACK FLOW PROTECT.DEVICE FEESUMMARY,
I am exempt under Sec B It P C for this reasonOUTSIDEFEES
DRAINS FLOOR ROOF,AREA,CONE). SANITARY Y_ N_
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION pIX.ITI PERTRAp SCHOOL TAA Y_ N_
❑I hereby affirm that I have a certificate of consent to self-tare,or a I RECEIPT N
certi(IateofWorkers'Compemationlau maraceriBledmpythereof&c. CAS EA.SYSITTf-1 INCAOUTLETS PAAKFEE Y N
3800,lab G
RECEIIT N
Policy# GAEA.SYS EM.OVER 4(FAM
) BUILDING DS ION FEES
Cam aS ny
�Ceftlfled copy is hereby famished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE I
❑CcrtlEed copy is filed with the city inspection division.
CERTIFICATE OF EKEM PTION FROM WORKERS' CREASE TRA' PAID
COMPENSATION INSURANCE SEWER"SANITARY-STORM EA.200FT. DRte RCCCI I#
(This a ionneednabecompldediftheper tistorosehundreddollars
(SIID)orlcss) ELECTA ENERGY FEE Y
t
I certify that the performance ofthe work HEATER W/VEYI'/
k forwhich this permit is issued,
I shall no employ any person In any manner m v to bemme sub)ect to the WATER SYSTT;l1/TRGTING
Workers'Compensation laws of Cali(omt.Date PAID
O Z Appilcant NEW RESIDENTIAL PLMB. SQ.FT. Date Reiser t#
Z NOTICE TO APPLICANT;11,after making t his CertBlcate of Exemption,you
should become subFa to the Worloms Compemuttion provisions of the Labor TOTAL:
Cod<,you most forthwith comply with such provisions orthis permit shall be BUILDING FEE
j deemed revoked.
'L — CONSTRUCTION LENDING AGENCY SEISMIC FEE O
CL IherebyafBrm that there is a construction lendbng agency forthe perform Tara. ! ELECTRIC FEE
7 Z ance of the work for which this perMt is issued(Sec 3097,C1v.C.) PLUMBING FEE
J O Lander'.Name .s'
)- Lender.Address Q'i'Y. - MECHANICAL PERMIT FEE MECHANICAL FEE
Lanifytha Huve read thisapplicatlon and statethat theabove information C FEES PAID:
J W d
is l agree to comply with all city and countyordinances and state laws PERMIT ISSUANCE
} N relating to building construction,and hereby authortm representattwx ofthis
d to entero the abovrmemlonM property(aria Ian ALTMORADDTOMECH.
Z
city poi P Percy Poct purpro . Date ReCei t#
(We)agree to save,indemNly and Inner,harmless;the City of Cupertino V MR HANDLING UNIT(TO 10,WO CFM)agaWt liabilities,judgment,costs and expenses which may in any way accrue SUBTOTAL:
against raid City In consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Wte FXIBAUS'T HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEALING UNIT(TO IWM BTU) Date Reuel
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safely Code Seddou25532(a)7 HEATING UNIT 1W,000 BTU) TOTA
❑ Ye. , M No
Wllltheappllontar tuturebuildingoccvpantuseequlpment ordevices VFNIILATiON PAN 6INCLE RFSIU) ISSUA YCE� T�
which emit hanardous air contaminant as cieflned by the Bay Area Alr
Quality blaagement District? BORER-COMP(3HPOR 100,000 BTI!)
4 Ye' .qNo
1 199'L
have read ehazar m materials requirements under Chapter 6.95 of BOILER-COMP(OVER100,000 BTU) iT)❑
the Califore Inith ASrfety Code,Sections 2550.5,25533 and 255M. I APR
understand at df the building don not currently veate ra,that it is my NEW RESIDENTIALMECH. SQ.FT
rapeaiis to ndlfy the occvpa oft rsqui ms which roust be � I�V� �V
Prior to an rtl(IatF ancy. Ly��Y Vr [�1i•4!/�
. // �' . D(
Own r a nv d agent Datf A
ISSUED BY..
OFFICE COPY