23480 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ed Idemilic.d.o PE)IATNO.
Building Address: ` ` ��\/ /�^ A (�O
V \.... 2 3 418
rat apct e:
CITY OF CUPERTINO-BUILDING DIVISION
Contratt 'eNarpe: Lk.No: APPLICATION I PERMIT
rch.d/En mer. BUILDING-FLECIMCALPLUMBINC-MFtCNANICAL CATEGORY C
8i Lic.No
QTY ELECTRIC PERMITFEE BUILDING PERMIT INFO
Addmu: - , PERhfIi ISSUANCE, J�
LICENSED CONTRACTOR'S DECLARATION 1�
IMreby offinn that lam lkmeed under provisions of Chapter9(mmmenc APPLIANCFSRESIDENTIA JOB DC$CHIPTION
license
Is In fon forceadefelon3ofthtBueineuand ProfeulonaCode,and my JOB
license is In(u0 faros and d(ett. PANELS
License Class Llcp '.
Date Contractor
ARCHITECTS DECLARATION 201-1PS
q�q�uu
00 I understand my pisns ehaB be used u public remrda 1 PS SQ.Fr.FLOOR AREA S/SQ.Fr.
Fi (9 Licensed ProfeulonslS ELECIIRICAL I ` CI{ I I) 213y1
<<�611 OWNER-BUILDER DECLARATION S IA CTRAPT
zp, 6 I lurmbyaffirm that lam exempt fromthe Cmdr.&m'e LicJA �
t e
following..Or.(Section 7031S,Business and Profession.Cor Ilot
OMt. P. POLE INST.KO muntywhichrequimaperMtromnaWct,alt¢rlmprovedepair anystm=m pnorm Its Wuance,also requirmtheapplicent fltto DEVICES I a
hV flee a signed statement that he is licensed pursuant to the provisionsof the
w(. Contractor's License Law(Chapter 9(commencing with Seclim, 00)ofDivl-
�O sicn3ofthe Buelnmand Professions Cede)orthatheis exempt them on ad MIN LELECTEC VALUATIOaN�
the bash for the alleged exemption. Any violation of Beetle n IASIS by an 7SSWITCIiESFD(T[1RF5 ?` L
�5
applicant for a permit subjects the applicant to a civil penalty of not more than V 1. V
Q five drcd dollars(5500). __ _SQ.FT, SI'OR[IH TYPE CONSTRUCTION
au NEW RESIDEMIAL ELECTR
as owner of the property,or my employee with wi,' jr wk
m pen.atlon,will dothe work and thestructure is not Intended rgft�ed(p -i
yy O ui (Sec.7064,Business and Pro(emlons Code:The Contra. Ia 'UaTw
L5�$ does nal apply loan owner dproperty who Wilde or Improves dory and OCC.CROUP RES IfNffS
AA who d0easuchworkhlnamlforthrwgh hbownemplayrea,pmvi}�1edd hotauch1 11 —
Improvements am not intended oroffemd far sale.If,hawever,th26 Idtor `
improvemnAbwld wlthlema yearofcomplMlon,theowe'r-WEderwill have
KT
tl(„Lurden of proving that M did net build or improve(orlpurpou�lp/IJi11� QTY, N T FEE
LJ I,ars owner of the property,am exclu.ively coo raQting wl/h'llfe6&V IT
FLOOU ZDNE APN
'mntractanlommtruct the pmjeR(See7064,Bus c end lkofmid
The Contractor's Lt..Law does rad apply to w owner d property who ALTER-DRAIN k VENT-WATER(EA)
Wilde or Improve thereon, and who mmade for ouch plojede with a FEE SUMMARY
�q¢((actor(.)bansed pursuant to the Contractor'.Llmnae Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B k P C for this tensors
OUTSIDE FEES
DRAINS FLOOR,ROOF,AREA,COND, SANITARY Y N
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION MR TRAP ^ —.t SC1300L FAX Y N
01 hereby affirm that I have a artl0ate of consent to self-insure,ora / RECEIPT N
3800,lab C.)
anlflmteo(Workeri (Se
Compematlonlmumnmoraanifledmpythemotc. CAS FA.SYSILYI.11NC6OUTLETS PARK FII? Y_ N
Policy N A. - RECEIPT N
�
Certified mpybfllN with th �'Q'-y—'F+-1 ./T CAS PA.SYSTCM-0VERd(EA) BUILDING DIV]SION FTFEESertNe yL� th the city e city Inspection division. GREASE/MDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
�C `VJI
CERTIFICATE OF EREMYI'ION FROM WORKERS' GREASETRAP P
COMPENSATION INSURANCE
�Q
(rhlssettion need net becompleted lithe permit bforomhundred dollars SEWER-SANITARY-STORM PA.20017. Recel
($100).'lose)
I certilyth.,In the performance of the work for which this permit Is Issued, WATER HEATER W/VENT/ELFJCTR EWR&FEE Y
I shag not employ any pawn any rtunner w u to become eubjett to the WATER SYSTEM/TREA71
Workere'Compenutlon laws of GII(ornia.Date Nic PAID (00
0 Z AppllNOTICE
NEW RESIDENTIAL PLMB._SQFr, Date Revel t#
Z O NOTICE TO APPLICANT:e orkmaaldrig'Compensation Cenn pro o(En oftteLalbu
shmld become subject to the Workers' provisi pmthlore of the Labor TOTAL:
W~ W Caonedr rtlood. wl(h comply with each proWlons orthb permit shall be
> deemed rcvokea. BUILDING FEE TJOO
aCONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby.Mrmthat there Is amutruction lending agency for the perform- i ELECTRIC FEE 1. QeS
M Z once of the work for which this permit b bsuea(Sce.3097,Civ.C.) T -
V O Lenders Name PLUMBING FEELL �a
I— !mines Addreas QTY. MECHANICAL PERMIT FEE
O W Icertlfythatl have mad thbappllmtlon and sudethat the above Information MECHANICAL FEE
IL isomerd.I agree to complywlth all city and county ordinances and elate law. PERMIT ISSUANCE FEES PAID:
>. N relating to building construction,and hereby authorim representatives of this
H Inspection to enter upon the above-mentioned property for Inspeon purpose.. ALTERORADDTOMECH.
Z
Z (We)agree to save,Ind emNfy an d keep harmless the City of Cu penlno Date Reeeiptp
agaimthabllltln judgments,coelsand expenses which may In anyway accrue AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL:
agalu sal C Immnseque ofth gplt permit. Q
`` Idsslu / AIR tNNDLING UNIT(OVER 10,(100 CFM) CONSTRUCTION TAX
IIIApplicant/Const. Date 7 EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA7 RDOUS MATERIALS DISCLOSURE
Ill the applicant or future building occupant store or hand In huardous HEATING UNIT(TO 100,000 BTU) Date Recei tN
mmerlai as defined by the Cupertino Municipal Code,Chapter 9.12,and the
lkalthsnd Safety Code, tt1on25532fti)7 BEATING UNIT(OVER 100,000 HIM TOTAL:
Yee No
Will the applicant it fuwm building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit harardous air mntarelmnts ars de0tad by the Bay Arca Air
Qu Mamgement d7� BOILER-COMP OtI'OR IOO,11008TU1
s o �q�/
ave read lheF s uhements under Chapter 6.95 of BOILER-COMP(OVER 100,000 RTU)'
the California Health Safety Code,Sections 25505,25533 and 25536.1 PAID
understand that if the building don not currently have a tenant,that It is my NEWRESIDENTIALMECH. SQ.FT.
rdponsiillty to edify the occupant of the exclijirnmrot.which must be met
prion uanaOLaL[nitic f �anry fJUN 01
r
Osel
er or authorimd agent Date ISSUED
L.
OFFICE COPY