23918 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: No Po p,T�z- �a 23918
re aJntAe:3 one:
Ra �+ f UYI£ /77 U o 99/ CITY OF CUPERTINO-BUILDING DIVISION �_iss—q^
c°ntradnr.Name: Lk."n:. APPLICATION /PERMIT L
lie R£rnoO Z/77(>- SceC/ Its 7-sIWC_
WC LQ IJPLY BUILDINGELECTRICATPLUMBING-MECHANICAL CA'fFS,ORV CONTROL•
Arcbltect/Englneed Tic,No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby,filrm that l am licensed under provisions of Chapter 9(mmmn APPLIANCESRESIDENTTAL JOB DESCRIPTION
Ingwithf...I in tell to.
the Buslneasand Pro(eulonaCale,and my �� �a.y
Ltear.la Ins (ortx and dfect. PANELS '11{/friA
License Clan Llep
Date Contranor —UP TO 2DOAMPS
ARCHITECT'S DECLARATION 201-IOM AMP"' clwgn
qqqq M0 I understand my plain shag be teed a public records. OVERIODOAMPS SQ.FT.FLOOR AREA #/SQ.FT.
Z� Licensed Pmfesslonl SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MLSC
1 herebyalRrmilurt l am exempt from the ContradoraLicense law for the
following reason.(5e tion 7031S,Business and Professions Code:Any city or
I"n9 mtntywhkbm(uirmaper ttom®ImMalter,knprove,demoliah,ormpar TEMP METER OR TOLE INST.
anystmdtre pdorto Its Issuance,also requlmtheappllant for such permit to
d file a signed statement that he Ii licensed pursuant to the provisions of the TOWER DEVICES
Contactors License Law(Chapter 9(commanding with Section 7000)of Divi- SWIMMING POOL ELECTRIC 1 sion3ofthe Butlnnsand Professlom Code)orthatheisexempttherefmmand VALUATION OO
6�3] the bash for the alleged exemption. Any violation of Section 703IS by any Un,E.ISSWFLCHESFIX TURFS M
O applies t for a permit suboetatheapplicant to a civil penalty d net more ban ow,
$ five hundred dollars(1500).
I,as owner olthe property, NEW RESIDENTIAL FLECTR SQFT. STORIES TYPECONSTRUCION'
V< eop dy,ormy employees inwlihwage a•thelewoe
mmpensalon,wBldothe work endtheetmdure V wllntended or offered for
O rale(Sec..M,Bu•Ineu and Profeeelom Code:The Coatradoes License law
r jg$ doe.notapplyto an owerof property who builds orimprovn thereon,and
whorl ae•enchworkbimveltorthroughhl•own employns,providedtha/wch OCC.GROUIa RFS UNITS
{ Improvem°nteare not Intended or offered for Is,If,however,the buildingce T
`I Improvement Is sold within one yearofcornpletion,the owner-builderwill have
tlgkurd en of proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLCODAONE APN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE ssssss'
contractors to construct the perfect(Sec 70K Business and Professions Code:
The Contactors License Law does not apply to an owner M property who ALTER-DRAIN&VENTWATER[FA)
Wilda or Improves thereon,and who contracts for such pRojed -
e with s FEE SUMMARY
c9atEador(s)Bernard pursuant to the Contractors License Law. BACK PLOW PROTECT.DEVICE
LJ I am exempt under Sec. B 4 P C for this reason
Owner DRAINS FLOOR ROOF,AREA,OOND. SANITARY Y N
. Dae RECEIPT p
bWORKMAN COMPENSATION DECLARATION
❑
1 FereafRrm ve that I hacertificatec of consent to self-0wrcFDCURFS PER TRAP SO{pOLTAX Y N
n
,or RECEIPT#
certillateofWorken'ComperaaRon lruunna ora certified mpythemof(Sec.
3800,Iab CJ GAS EA.SYSTEM-1 INCA OUTLETS PARRFEE Y N
Policy p RECEIPT'p
CAS EA.SYSIFMAVER d(FA)
Com env Thi, P _ O _ BUILDING DI VIRION FEES
�Coditied copy is he d with he cit. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECIC FEE
�CertlRed copy V filed with the city inspection division.
CERTIFICATE OF UEM PTION FROM WORK ERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER SANITARY STORM EA.2WFT. Date Remi t#
(0),e lsdlon need not be completed If the permit V Forane hundred dollen
(E100)edify that
WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I cenot emp o the performance of theworkmanner so as to
this becmitome
c Wued,
T shall not employ any perm"In any manner n u to became object to the WATER SYSTEM/TREATING
Workers
an Compensation Laws of California.Dale PAID
O Z ApplicNOTICE
OTICE NEW RESIDENTIAL PLMB._SQ.FT. Date Recei t#
Z NOTICETO esubje AN'T:IfW.rkx.'C. pc Certlfkrovis Exemption,you
shml,you=a forth tmthe Workers'Compewiio provhis permit
Lab be TOTAL:
Uj N dremcdumtaforthwllh comply with euchprovlelonsmthls pertNt shallbe BUILDING
IL � domed revoked.
(LCONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is•mmtrociion lending agency for the perform ELECTRIC FEE
7 Z ance of the workfor which this permit(•Issued(Sec.3097,Civ.C.) ��
I) O Iendcrs Name PLUMBING FEE
LL N Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icertifythatlhave readthlsappBallonandstatethaHheaboveinkmandion
1 bmrreet Iagree to comply with all city and county ordinances and pate laws ` PERMIT ISSUANCE FEES PAID:
} relating to building construction,and herebyautbotlae representatives of this
I— 2 dtytoenteruponthe abovcment(oned property for Inspection purposes. ALTERORADDTOMECH.
(We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
V agaWt liablUtM,Judgmeni,m sandexpemnwhkh mayinanywayacaue AIRHANDLING UNIT CO IO,ODOCFM) SUBTOTAL'
age"to City In consequence of th 11 of hispennit AIR HANDLING UNIT(OVER 10,WOCFM) CONSTRUCTION TAX
—9 2 CONSTRUCTION TAX PAID:
HAZARDOUS
Signa of ApplnData IXl-IAl15T HOOD(W/DUCT)
HAZARDOUSOUS MATERIALS DISCLOSURE
Willtheapplicant
ned byre futurebuildinggocmpant sera hhandlc haaardoue HEATING UNIT(TO 100,000 BTU) Date Rece1 t#
I lealt ai a•defined by the Cupertino Municipal Code Chapter 9.1 2,and the
I Fly.
and Safety Code Section 75532G)7 bIGTING UNIT(OVER t00,OW BTU) TOTAL:
Yn No
Will applicant Iture buildingocmuse equipmentdevices VENTILATION FAN(SINGLE RESID) ISCPI
whkhscratams.irotaminaleas defi.ed by the Bay Area Air � E
BATE
Quality ManagementDistrict?
BOILER-COMP pI-RPOA 100,IX0 BTU)
4Yro 4Na JUL
nave mad the hazar ousmae,Sl di..25505tsunder Chapter 6.95 of BOILER-00,%4P BT11) lflflLfl
the
understand
that if th k Safety Cade, of cu ru currently
have
a to ad,that i 1 s��aa�7L
undealandthat it the building does not mrrcnlly have•tenant,that ltVmy NEW RESIDENTIAL MECH. SQFf. /s y
responsibility to notify the occupant of the requirements which must he mel Hill Uf CUrtnIi U
prior to issue ce of a CertlOale o(Ottvp nry.
7—/—F2 ���\(����� ��s
Owner or °reed agent Date ISSUEDSY —W—# - /
OFFICE COPY