23835 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO. '
Building Address: 23835
10391 I V 6 GQFST OUICT
ersName: one; ApPffCA711679U97IrrAE=
N V 1 T S -73 d -�3 CITY OF CUPERTTN0.BUILDING DIVISION / �l 2 -IR Z
c tr•/jp'•Nare: Lie.No: APPLICATION / PERMIT (¢ L J l
BUILDINC-ELFiCTRICALPLUMBING-MECIIANICAL CATEGORY CER50LN
`� ArchitM/Engineer, k. o:
QTY ELECFRICPERMFF FEE BUILDING PERMIT INFO
Address: a PF3tMITI55UANCR ❑ ❑ N ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm that lam ficensed under prChapter9(comments AIPLIANCFSRESIDENTIAL
MON
IngwlthSection 7000)otDlvsim3oftheBuslnessancl'refeaelonaCode,and my JOB UP.
license Ie in full f and died. PANELSOL
Llmna Cleats('
Date Conhacor �/U✓
ARCE11=1 D AT ON 701-1000 AMPS
re0 O I understand my plans shallbe used as public records. OVER IOW AMPS SQ.FT.FLOOR AREA S/SQ.FT.
Fi Z�Z Licensed Professional SIGNSELFGTRICAL
<6 OWNER-BUILDER DECLARATION A,L E D
�+a SPECIAL CIl2CUIT/MISC
IN
7s' owing yaxon. ectionmexem)t from Bu.mageContradokuaiCnse Gwfor the MP
E
pp following reason.(Sedlon 70315,Bbelnem and Profeabne Cade:Any cty or 't��^��y'LLL///��J'
O Z.. TEMP.METER OR POLE INST.
county which requlmaaperMttomnaWgalter,improve,demolleh,orrepair pp
anystrudure prior to its lauance,alanrequlresthe appllcantforsuch permit to POWER DEVICES 77 —JZ
O Ilea signed statement that he Is licensed pursuant to the provisions of the
ud� Cmiracbm.License Law(Chapter 9(commentlng with Section 7000)of OIW- SWIMMING NOL ELECTRIC
sion3ofthe Business and Prefealona Ccde)orthat he is exempttherem
fmand VALUATION
the basisfor the alleged exemption. Any violation of Sec70315 by any OUILETSSWITCHESFIXTURES
600 appgcanlfora pemNt subjede the applicant too dull pemlty of not more than
five hundred dollars($500).
NEW RESIDENTIAL ELFG'IR SQ.FT.
7 6 ❑I,as owner of the property,or my employees with wages a ffelr sole STORIES TYPECONSTRUCTION
compensation,will do Business work and the s Code:Th not Intended or offered for
O vie(Sec.7ply to in
df property Code:The Contraor
rimprvesor's Llceae law
does 3$ whodotsuch torn owner ofthroug hiswho
nemporlmproovided thereon,and OCC.GROUP I DNTTS
who ovementswork t int eft ed motioned
ots h Neownemployee•,provided that such
improvementsarenot Intended earofecd(orale.If,however, rider ill have TOTAL:
Improvement V sold within oneyearofcompletion,the owner-bugderwlil have
tl){�urden of proving that he did rant build or improve lm purpose of sale.). QTY. PLUMBINGPERMIT FEE
L as owner of the property,am exclusively contracting with licensed FLOOD ZONE APN
contractors to construct the project(Sec.7044 Business and Professions Code: PERMIT ISSUANCE
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT WATER(FA)
Wilds or improves thereon,and who contracts for such pwtoncts with a
cgllLfactor(s)licensed pursuant to the Contractor's License Law, "FEE SUMMARY
5I am exempt under&c. B&P C for this reason BACK FLOW PROTECT.DEVICE
01 Jet nE FEES
Owner Data
DRAINS FLOOR,ROOF,AREA,GOND. SANITARY Y N
WORKMAN COMPENSATION DECLARATION . RECEIPT'N
❑I M1ereby affirm that 1 have a certificate of consent to self-insure,or F'IX'IVRF_41'ER TRAP SCHOOLTAX Y N
mnifime of Workers'Compenattonl urance or a oertlfied copy thereof(Sce. RFGQPfN
3800,Tab C) r / y GAS F.A.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Y f1 RECEIPT It
GAS FA.SYSTEM-OVER 4(EA)
y BUILDING DIVISION FEES
Certifiedy bycity
formatted. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECRFEE
❑Certified copy laflleled withhthethe tlty inspection division.
CERTIFICATE OF EXEMPTION FROM WOR KERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(ThissMloonced not hecemplatedifthepemdt tsforonehundreddollan SEWER-SANITARY-STORM EA.SFT. Date Remi t#
(fl fWATER HEATER W/VENT/ELECTR ENERGYFEE Y N
Iondimrtlty that In the performance ofthe work for which this permit Is 6sucd,
1 shall not employ any person In any manner w a to become subjed to the WATERSYSTEM/TREATING
Workers'Compensation laws of California. Date PAID
O Z Applicant NEW RESIDENTIAL PLM8, SQ.PT. Date Recei t#
Z O NOTICE TO APPLICANT.If,after nuking l his Certificate of Exemption,you
should become subject to the Workers'Compeaatlon provisions of the Labor TOTAL:
CCN Code,you=at fod hwith comply with such provisions or this permat shall W BUILDING
FEE
`> deenrd revoked.
III
C CONSTRUCTIONIsacom LENDING AGENCY SEISMIC FEE
I hereby afOrm that there i a erm�Bts issued
d(Sec. agency for the perform- ELECTRIC FEE
� Z once of the worklor which this permit laissued(Sec.3097,Civ.
O O lenders Name L PLUMBING FEE
LL I- Lender§Address QTY. MECHANICAL PERM I FEE MECHANICAL FEE
OW Imrtlty that l have read l his application and state that theabove lnlormailan
IL Iscorred.I agree to comply with all cityand county ordinances and state laws PFAMTTISSUANCE FEES PAID:
r W relating to building construction,and hereby authorize representatives ofthis
H Z city to enter upon the above-mentioned property for inspection purposes, ALTER OR ADDTO MECH.
_ (We)agree to save,IndemNfy an d keep harmless the City of Cupertino Date Receipt#
agalatllab0ldn,judgments,cosband expenxro which may in any wayacwe AIR HANDLING UNITED 10,000CFM) =CONSTRUC-nONTAX
:
against said City in consequence of the granting of this permit
AIR HANDLING UNIT(OVER 10,000CrM)
Signature of Applicant/Contractor Date FXHAUS'T I TOOD(W/DUCT) :HAZARDOUS MATERIALS DISCLOSURE
Will the applica at or future building ouavpart atore or ha ad le hazardous HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertl no Mu nicipal Code,Chapter 9.l Z and the Ilcalth and Safety Cade Secion 25532(.)7 HEATING UNIT(OVER 100,000 BTU) ��
❑Yes o
Will the appIkx r tum building occupant so equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air roma mfanta as defined by the Bay Area Air
Qa lity Management Bider? BOILER-COMPOIB'OR100,IXDBTU) PAID
4Yea o
haveread lee ser cast rCWt ,Sbdi. 25505,sunder Chapte4. I of BOILER-COMP(OVER 100,0B)BTU)
the Calitomla]Iealth&SafetyCale,Sections 75005,25533 and 25534. 1 t
understand that if the building does not curmntly have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT JUN 15 1992
responsibility to notify the occupant of the mquiremsnt•which must be met p
P" to iss ncc ole Ce o Ompanry. ` CII Y VI" CU"tITV I
Owner or authorized agent rAte ISSUED BY;
TOTAL:
OFFICE COPY