23165 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm'ect Identification 7 PERMIT NO,
Building Address: 23165
M P2. TS�Ix1�T 21677 RAIU IOLO X>R, C 7uvc�.
wnere area. one: - p PITl7A1T01T9U9PT7rAL=
Pit L> , T S-E>,I CITY OF CUPERTINO-BUILDING DIVISION Q Z
CoTn-tr�ac�torss Name: Lia.Na: APPLICATION / PERMIT
Vr-lv Its 'r-- C-Z(3Tro BUILDING-ELECTWCALPLUMBIN -MECHA C CATEGORY - COf.�R
Archuact/Fngincer. Llc No: ly
11�r QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: 51ta /OST ` LR PERMITISSUANCE 1KL ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION J�
I hereby affirmthat l am licensed under provisions of Chaptcr9(comment, APPLIAN RE E JOB DESCRIPTIONfngwlth Secd.n 70KBi Divtdon 3 afthe Business and Prmfea don.Code,and my
license Is in full((�t�rcae and effect. '/�� K
LlanmC6ss_jS
DaLffec _�S6riiS {/,/
te Contractor
ARCHITECTS DECLARATION pr''
U(10 AM?xv A A I rA i d
oto 2 I understand my plans shall be used m public records. OV 000 AME SQ.FE FLOG EA S/SQ.FT.
qqq O �s�1�
�j Licensed Professbnal SIGNS LECTRIC C.GNLi
6 OWNER-BUILDER DECLARATION SPECIALCIRCUI
I herebyaffirmthat lamexemptfromthe Contractor's Licence Lawforthe
qqqqq following reason.(Section 7031.5,Business and Professions Code:Any city or
cmntiwhich requires a permt tomrutruct,alter,Improve,demolish,ormpalr TEMP.MEIEROR LEINST
anyatm=mpdortothhmancgalwrequfrestheappllantforsuchperMtlo POWER DEVICES
[5 file a signed atatement that be h licensed pursuant to the provhiora of,the
Owt`n Contractors License Law(Chapter 9(commencing with Section 7000)of Dlvi- SWIMMING POOL CTRIC
m
sn3ofthe Business and Pro(emlom Code)orthat he h exempttherefromand VALUA'1](Ilj�vat/
<� the baah for the alleged exemption. Any violation of Sectlmn 70315 by any OUTLETSSWI F7%TURFS /r��
applicant fora permit wbject.the applicant to a civil perulty of nd marethan 006
a. five hundred dollars(§500). NEW HSI AL ELECTR
..�n [3I,as owner of the property,or my employees with wager a!their sole SQ'FC. STOW ES TYPE CONSTRUCTION
compensation,will do the work and the structure Is not intended or offered for
O as le(Sec 7044,Business and Professions Code:The Contractor's License Law
S$ does not apply to an owner of property who build,or improves thereon,and OCC.GROUT' RFS.UNITS
whodoosuchworkhimselforthrcughhlsownemplcyee,,providedthatmch
Improvements are not intended proffered for sale.IS however thebuili ing or TOTAL:
Improvement Issold withlnoneyearofcomplatWrythe owner-bullderwfll have
the human ofpmving that he did nmbulldorimproveforpurposeofsale.). QTY. PLUMBING PERMIT FEE
IUJ —FLOOD ZDFIF. AI'N
4 as owner of the properly,am.7044,Business
contracting with licensed PERMIT ISSUANCE
TheconCotoratocomtmd Licentheproject(Sec.app) tonessand P f property
Code:
The Caor fir rat License Lawon, does not apply tom owner of property who
halide t r(reproves thereon,and who mn<rects for suchseL ptojem with a ALTER-DRAIN&VFM-WATER(EA)
cq:11 a exempt
under antSec.,the Conmactorl License law. BACK FLOW PROTECT.DEVICE FEESUMMARYIJMMARY
I Lf I am exem)rt under Sec B&P C for this sawn
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date _ RECEIPT p
WORKMAN COMP ENSATION DECLARATION p f I Sp100L TA% Y N
01 hereby afOrm that I have a artiflcate of consent mself-Inmre,or 'I � RECF7PT N
mrtifiatea(Workers'Compemationlmuranmrnaartlfkdmpythemof(Sec. GAS EA. STEM-[INCAOUTL 5 PARK FEE Y N
3800,I C.) ,
CoPolm an GAS!P.A. 894M-OVER 4f(� RECGE'TN
y BUILI3INCDIYISIO FEES
rtified cop] h hereby furnished. GR SE/IND I:3WASTEL PLANCI'IECR FEE stat _
rtaied ropy h filed with lM city WpecHon division. � LOO
CERTIFICATE OF EXEMPTION FROM WORKERS' GR ETRM
COMPENSATION INSURANCE PAID
SEWER-SANITARY-STORM EA.20017T. Date eel t#
($100)o
(T certify that,u lasslon need not be completed If the permit is(or one hundred tlollare
ify th bmWATER HEATER W/VENT/ELECTR ENERGY , NyG,/1
I at In the performance oflhe work(orwhich this Permit h
ed,
I.hail not employ any person In any manner w as to become subject to the WATER SYSTEM/TREATING
Worker.'Compensation Lawsof California. Date PA
C' Z ApplicaNOTICE
OTICE NE'WRELDENIIALPLMB, SQFr. a ecei t#
Z O NOTICETO uld esubJe ttothe aaerm'Comcking Compensais tion
of&empteLyou
H coe,you=at forthwith
the Workers'such provisions;
provhis perions it s Labbe T -FAL:
.� N Ceacredumuet(orthwithcomply with such proWiov orthhperNt shall be U G +.a
W � deemed revoked.
d c CONSTRUCTION LENDING AGENCY SEISMIC ITE
Ihembyafflrm thatthereisacotraction lending agency for the perform- ELECTRICFEE
D Z ance of the work for which this parMt is Lvued(Sec.3097,Civ.C.) TOTAL:
U Q Lender'.Name PLUMBING FEE
IL 1- Lender',Addres. QTY. MECHANICAL PERMIT FEE MECHANICAL FEB
OW I artlfythatl have read thisappllcattonand statethatthe aboveinforrution
S hcomect.I agree to comply with all cityand county ordinances and state laws PERMIT ISSUANCE FEES PAID: -
} N relating to building construction,and hereby autharn
ace reprcntatives of this
Z city to enter upon the above-meationed property for inspection purposes, ALTERORADDTOMECH.
(We)agree to save,Indemnify an d keep harmless the City of Cupertino Date eeei t#
L) against liabilities,judgmenta,cossaini expenses which may in anywayaame AIR HANDLING UNIT(TO 10,300 CFM) $U TOTAL'
ago Wt said Ci maeaparce of the gn tag of this permit.
AIRHANDLINGUNITIOVER10,"Cl M) CONSTRUCTION AX
n `7- 3 i- Z.
S natureo ppliwnt/Contractor Data D(HAUST HOOD(W/DUCT) CONSTRUCTION AX PAID:
HAZARDOUSM ERIALS UI SCLOSURE
Willtheappilant or future bull ingomipant store or handle havardmi; HFA71NC UNIT(TO 100,000 BTU) Date ei t
material as defined by the Cupertino Municipal Code,Chapter 91Z and the
Health and Safety Cade Section 25532(x)7 HEATING UNIT(OVER 100,000 BTU) TO
RYes MN.
UB theapplicant or future building pact use equlpmnt or devices VENTILATION PAN(SINGLE REBID) ISSUANCE DA .E
which emit havrdous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP OLE OR 100,000 BTU) A
4 Yrs No T
have readtheh.r us rtulariats requirements under Chapter 6.95 of BOILE R-COMP(OVER 100,000 BTU) AID
the Glifemla Health&Safety Code,Sections 25505,25533 and 25534. 1 ��
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECFI, SQ.FT.
rnponsibllity to notify the occupant of the requirements which must be met ai
1
prior to lasu...of a Certificate of Occupancy. CI f j' 198/
/-r,
Owner or authorlract agent Date ISSUED B
TOTAL: —
OFFICE COPY