23665 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proje mentifcation PERMIT NO.
Bu°ding Addre": 23665
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CITY OF CUPERTINOQBUILDING DIVISION 9- Z _ 'l
C�°Bad @Name: Lic.No: Y APPLICATION I PERMIT
BUILDINGF],ECTRICALPLUMBINGMPLHANICAL CATEGORY CONTROL M
Arehkett/Enginnr. Ile No:
QTY ELECTRICPERMIT FEE BUILDING PERMITINFO
Address:
PERh9TI55UANCE ❑ ❑ ❑
LICENSED CONTRACTOR'SunderDECns of ChON 'LJ
I hereby ion700ha lamlkensed 3oftheerprnuiand odessioer9(coand my APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwhh Section700D)of Division lthegutl�'nreaand ProlnsloneCode,and my
license le In fin form deflect,
ea- PANES
Date — �, ,�
Date Contractor N —UP 10 200 ANIPS
ARCHITECTSDE LARATto 301-1DOOAMPS
I understand my plane @hall be used as public record.. OVER I"AMPS SQ.FT.FLOEIR AREA $/SQ.FT.
6e �j Limned PmIx.lorul SIGNS ELECTRICAL
< GFtI
OWNER-BUILDER DECLARATION SPFGULCIRCUIT/MLSC � L� ,
Z [hereby afOrnlOWNE -BUIL ER DE LARAR.t'e Llmna Law(eathe 'V
oo following reason.(Section 70115,B..Wax and Professknw Code:An R or
OZ� y ty TEMP.Mh7FTt OR POLE INST. I 'I D
P countywhich requlrnapermitbcuratuR,alter,improve,demoWh,orrepalr - P.�
O anystmc mpriortoit.issuance,al.omqulrvstheappliantfm.uchperWtto POWER DEVICES Kz-) 1 (� h.[
file a signed statement that he la licensed pursuant to the provislons of the 1 r i R
�e� Contractor's License Lew(Chapter 9(commencing with Section 7000)of Divi- A LUATIO
o M.A3ofthe Buelneasand Pr f.a mCod.)orthatbei exemptthertfmm.nd SWAIMINC POOL ELECTRIC V
Othe basis for the alleged exemption. Any violation of Section 7031.5 by any OLITLETSSWITCHESFD(TURFS ATE
lMZMcc applicant fon permit subjet/e the applicant to a civil penalty of net moretlun
five hundred dollars($SM.
NEW RESIDENTIAL ELECTR .FT.
�m ❑I,asOwner Of the property,or my employees inwithwagestheredole STORIES TYPE CONSTRUCTION
mmpe c.70K But dothe ess and Pr a smomuude:The C intended or License
offered for
dale(Sec.apply
to an ow and f property
rope ty Code:The C imps l'a Limas Law
don nonsuch toanowner of1prough hison emoymprovnthereoryand OCC.GROUP RES.UNITS
who ovenuchwork hlmnnded oroffe hisownemployees,provided thrtsuch
Improvementsartnet Intended.cofferedfor sale.If,however,thedeer building Or TOTAL:
Improvement proving
one id mat coils or I rytoe a for purpose
rpose of fll sahave
tflR,jurdn ower of the t he property,am
bead orbnpmve(oring wieofnkJ. QTY. PLUMBING PERMIT FEE FLCODZONE APN
Ltr 4 as owner of the property,am exdutl elyBusiness
contraessand Ing with licensed aCode: PERMIT ISSUANCE /
mntaR.retommWRthe protect(Sec7 apply
Bto inane of pro ow Code rr•f/
The Caor Impr'e ca then Law aces net apply to f owner of property who ALTER-DRAIN&VENT-WATER(EN
Wilds or Improves[herton,and who contracts(ea such pl.jeds with a
o tactor(.)boomed P...m to the Contractor's Lirenae Law. FEE SUMMARY
L-J I am exempt under Sec B&P C for this reason BACK FLOW PROTECT.DEVICE
Owner DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N_
Date RECEIPT
WORK MAN CO have
rekTION DECLARATION FDCrURPS PER TRAP SCHOOL TAX Y N
❑I hereby affirm that I have o Ins.a c of Conant to copy thereof
(S • RECEIPT N
mrtl0ate of Worken'Comperaatl.nlmurance eaa mrtlfkd copythemof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
3300,Lab C3
Peaty N /7 9 3 3 3�Z RECEIPT x
Com an �F- .! GAS EA,SYSTEM-OVER4(EA) - BUILDING DIVISION FE ES
MCertnied copy is hereby te
�Certilicd copy is filed withh the city
Inspection divlelon. GRFJSEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
ty
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(ITIS radion need net be completed lfthe permit BloronchundreSEWERSANTTARYd dollars STORM EA.20OF1'. Date Recef tit
($100)or less.) - WATER HEATER W/VENT/ELECTR e s ENERGYFEE Y N
I artily that In the performance of the weak for which this permit b blued,
I shall not employ any person in any manner n n to becomte subject to the WATER SYSTEM/TREATING
Worken'Compenabon lawn o(Gllfomla. Date PAID
O Z Appliont Date Recei t#
Z O NOTICE TO APPLICANT:If,after raking this Certnlate of Exemption,you NEW RESIDENTIAL PLMB. SQJrT.
Hshould become subFat to the Worken'Comperaatlon provisions ofthe Labor TOTAL:
cc N Code,you=at forthwith comply with such provisions orthis Nrret.hall be
> deemed revoked.
TIBUILDING
a C
CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby.Mrm that there is a construction lending agency for the perform, ELECTRIC FEE
D Z anm of the workfor which this permit is Issued elee 3097,Civ.Q TOTAL:
c221 1
V O Kaden.Name PLUMBING FEE
LL Lender.Add mn QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I mrtifythat l have read thbappliation and tlatethattheabcve information
IL bc.rrett.l agree to comply with all city and county ordinances and state law. PERMIT ISSUANCE FEES PAID:
U) rely ing to building construction,and hereby authorlu representatives of this
F Z city to enter upon the above-mentioned property for Inspection purposes. ALTER ORADDTO MECH, Date RtN
— (We)agree to ave,Indemnity an d keep harreea the City of Cupertino eCel P
agaWt liabilities,Pcigments,cents a nd expenses which may in any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
ag t aid City In Conary@ oft granting efthis permit.
M_ r- AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCFIONTAX
SI n core of Applicant/Contractor Date EXHAUST HOOD(W/DL'C'n CONSTRUCTION TAX PAID:
HAZAR DOLS MATERIALS DISCLOSURE
Willtheapplia est or future building occupant store or handle hazard... HFATINGUMT(TO 100,0008TU) Date Recci tic
material m de0ned by the Cupertino Municipal Code,Chapter 9.1Z and the
Iicalth and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
Rill
�]No
ill the applicant Orfuture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSSUTfWATE
which emit haeardous air consminantsas defined by the Bay Area Air Ir 40 E 6J
Quality Management DTA rid? BOILER-COMP Of IP OR IW,,001 BTU)
I
Y. (❑''O No C /�
havcrmdlhehazardoue materials requlerments under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) ` \ SEP 24 199G
the California Health&Safety Code,Sections 25505,25533 and 25534.I \
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FI
responsibility to ndily the Occupant of the requirements which must be met CITY lJr t,allrCnIIIVV
prior t.Issuance of a Certificate of Occepancy.
Owner or authorized agent Data TOTAL: ISSUED BY: Gr
OFFICE COPY