23175 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES= USE BALL POINT PEN ONLY
BuildingProject Identification. PIB TNO.
Bulldln Address; T� LOT I-tg 23175
suer, ams: {'y7one: p
V a 1 WK, !; '� CITY OF CUPERTINO-BUILDI G DIVISI N 1
c eName: 'J$2y APPLICATIQN /P I I`
s 7 BUILDING.ELECTRICALPL G-M CAL CATEGORY CO
rch act/Engineer, Lie.Na
'F �a,,,. QTY EL TRIC ERMI PEG
BUILDING PERMIT INFO
Addresro s:! Ju LldFe d AWia� PERMIT, UA res ® { f
LICENSED CONTRACTOR'S DECLARATION LF7
I hereby affirm that am licensed under proIslons of Chapter9(commmc- - AIJUAAJOB DESCRIPTION
It ..h i.fian700Wof DlvWon3 efthe Buelneasand ProteWonsCode,andm ,S y_
Lice. blas force and ca `ve`y'v
License CVs LILY
Date Contactor
-ARCHITECTS DECLARATION 201-1
as CZ I unaeatand my ptaro shall be used as public records. OV SQ.FT.FLOOR AREA - Ss//SSQ.FT.
!G (/ Licensed Profeshml SIGN L CAL �' /i3p
c� OWNER-BUILDER DECLARATION SIsECNLCBiCUIT/MSC TT
zH, 4 Ihereby afRrmthat I am exempt fromthe Contract.e.LicenselAwforlhe
p following reason.(Section 70715,Business and Profession,Code:Any city or
O�Z H TEMP.METER OR POLE INST.
county rcquiroa pemdtlommrequid[the
eapmvant for ech,ormitrepir
to
q .� any structure Insets its bmance,aW requlrcstbeappBcant forach permit to POWER DEVICES
4 file a signed statement that he b licensed pursuant to the provisions of the
3a Contactors License Law(Chapter 9(commenting with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
X03 sion 3 oflhe0uahme and Pmfeslons Code)orthat bete exempt therefromand
O the bash for the alleged exemption. Any vlda0on of Stolon 70315 by any OUTLEISSWITCHFSFIXTURES
appB¢nt fora permit subjects the a pplleam to a civil perulty of not marc Ilan
ties hundred
..,ofhe pr). NEW RESIDENTIAL ELECJR SQ.FT, STORIES TYPE -CONSTRUCTION
..�nf-jLpe ac owner of/he property,or h. employes with ween as thele sale
m1. e.t0K B.,ldoao.rel eafrag aCoda,rele ContraMed orcense d forLw �O
O We(Sec 7644,Bushes and Profanity Code:The Contractors License law
$ does does
apply loan ummerdtheaug his own mploys or mprovnthermryuch OCC.GROUP RES.UNITS
who donunts am work
notIntended orargh Msow ac.If, ow provided that mor
Improvement are net intended proffered loreale.I(,however,the building or O
Improvement iasold wlthhomyearofcompinbrytMe ner.bu0derwill have
t"eden of proving that he did not build orimprove for purposcofsale.). QTy-I PLUMBING PERMIT FEE
U L ae owner of the property,am exclusively contracting with licensed FLOOD ZONE APN
contactor,to mretruct the project ISM 70K Bushes and Professions Code: PE rr ISSUANCE
The Contactor,License Lew dm not apply to an owner of property who
builds or Improve thereon,and who contacts for such p(ojects with a ALTER-DRAIN 4 VENT-WATER(SA) _
aq�[+ctar(s)Licensed pursuant to the Cmtnctora License Lew. FEE SUMMARY
LJ I am exempt under Sec B k P C for this mann BACK W j
DRAINS t F;AIWA; NIT BY Y N
am QUTS1 DE FEES
Owner Date ` V `9' 11 RECEBTI
WORKMAN COMPENSATION DECLARATION S-PER 9v{ TAX Y_ N_
QI hereby affirm that I have a certlliale of consent to self-Insure,¢aFD(TURERECEIPT Y
3800,iAb C.)
cenl6ateofWorkers'CompewHonlmuran¢¢amnHkdmpythereof(Sec. GAS Igl gp�� � PARK Y N
RECEIPT
On GAS EA.SYSTFMAVER 4(FA)
Com any BUILDING DIVISION FEES
On
ropy Is hercbytthehed. CREASE/INDUSIRL WASTE INTERCEPTOR PLAN --C E
C]Certified copyV filed wllh the city Inspection division. (,/L Y
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP P
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.XIOFT. Date Revel t#
c•IThlssection need not be completed if the permit V foram hundred dollars /�
(E100)¢ly that
WATER HEATER W/VENT/CLECTR ENERGY FEE Y S �
I¢rtl(y that hthe p ormance o(thewark(arwMch rbp Ht le Issued, 1
I shall not employ ny on In any manner n as �i to the WATER SYSTEM/TREATING PAID
Wmkers'Comp tin Wa of California.Date
( O APPII¢nt NEW RESIDENTIAL PLMB. SQ.Ff. Dale R t ,�
.Z O NOTICE TO ANT:If,after nuking this CertHlom.1'Exemption,you
Hshould become subject to the Worker!Compematlun provisions ofthe Labor TO' AL:
c N Code,you at forthwith comply with such provlsbm mthb perrnitshall be
W > deemed revoked.
a c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby atRrm[hat there is a commuction lendingagency for the pedorrry ELECTRIC
-� O an¢ottheworkforwhb
lchthis pc motLssued(Seo3097,Civ.C.) '
Iaoders Name PLUMBI
LL t- lender,Address QTY. MECHANICAL PERMIT FEE MEC I E
U Icedlfythatlhavereadthbapplk tbnaMnalelhatlheabovehfornution
W is comet.I agree to comply with all city and county anllnances and gate laws PERMITISSUANCE FE I
} IL relating to building construction,and hereby authorize reprexnt.Hvesotthis
N city to enter upon the above-mentioned Property far Inspection purposes. ALTERORADDTOMECH.
? (We)age to save,indemnify and keep harmless the City of Cupertino a Recti ! kk
L.I ,gal. In,' d n cane and expenses which may In a wayaacm AIR HANDLING UNIT(TO 10,000CFM) SUBTOT
teat CI n o oath grpemmwIto this pe nit. AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTI NTAX
Igna B¢nt/ ontraclor Data
IXHAUSTHOOD(W/DUCT) CONSTRUCPIO TAX PAID:
HAZARDOUS MATERIALS DISC OSURE
tIllthe appE¢nt or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date XRoceivt#
material as defined by the Cupertino Municipal Code Chapter 912,and the
Health and Safety Coder�Section 25532(a)? HEATING UNIT(OVER 100,000 BTU)
❑Yee II No
Will the applicant or future building occupant use equiprrcnt or devices VENTILATION MIST(SINGLE BE Sit)) ISSUANCE DATE
which emit hazardous air contamlmm,as dented by the Bay Area Air
Qua llty Management District? BOILER-COMP(3FP OR 100,000 BTU) I��
Yn (''�iNo Ifs p�
I'have read the Fuar`fi ous materials requirements under Chapter A95 of BOILRR-COMP(OVER 100,(100 BTU) 6J -
the California Health k Safety Code,Sections 25505,25533 and 25534.1 1 ;!(/t
undeatand that lithe building don not mrrcntly have atenanq that It le my NEW RESIDENTIAL MECH, SQ.rrp YJI ��'I'V
responsibility to notify the occupant of the requirements which must be met ., /M
prior to issuance of a Certificate ofOcceepancy. C'47'1e p a
Owner or uthodad agent Date - ;+
ISSUED BY:- -.ai-Y-Y-"
- O
OFFICE COPY
CITY OF CUPERTINO
, 10300 Torre Avenue Telephone 252-4505
INSPECTION NOTICE
I WO
JOB !
ADDRESS TIME
DAILY REPORT ❑ CORR CTION NOTICE ❑ VIOLATION❑
TYPX INSP.:r SLOG. ❑ ELEC. ❑ PLBO.❑ MECH. ❑
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WEATHER —INSP.
CITY OF CUPERTINQ
10300 Torre Avenue Telephone 252-4505
INSPECTION NOTICE
BUILDING DON
JOB ATE - /9 -3
ADDRESS TIME
DAILY REPORT ❑ CORRE TION NOTICE VIOLATION❑
TYPE INSP.: BLDG. ❑ ELEC. [:1BG.❑ MECH. ❑
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WEATHER I SP.