23538 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO,
eufiding Address:P23538
3 tit�o b �
ner. sues::I A14 Q45' Aza a w ;"_ISO$ CITY OF CUPERTINO-BUILDING DIVISION
^tradorsNama: ue.N APPLICATION /PERMIT b' Z
�� � CS-,r . .2ZO3 2 e S;3 BUILDING-ELECTRCALPLUMBINC-MECHANICAL CATEGORY CONTROL#
Architect/Legiver. Lk.No:
046frd(AA*' BUILDING PERMIT INFO
A dress
(O 5• 1!N%Dn,n qr0 fjzSn QTY ELECTRIC PERMIT FEE
s PERMITISSUANCE �y0
LICENSED CONTRACTOR'S DECLARATION L
I hercbya(firm that l am Licensed under provisions of Chapter9(mmranc APPLIANCESRESIDE L JOB DESCRI'TION
ingwith Secdon7000)of DiWkon3 ofthe Buslnessand ProfessionsCode,and my
license Is In full farce and effect. A
LicenseClass a 76,3 Lle.# 2zO 9.42.. 11 i IPOD�
Date X23+q�eDntarxor - -ry( j.j{ -
ARCHITECTS DECLARATION U PS )
ceO Zp ]understand plan slyUbe used apublle¢ands. V' 1000 .FT. '.p .AREA $/SQ.rF.
@�C MJ/au - G/HL�AL'�JL/!7A//l 9GNSE C 1— 1 R
<k ly u Licensed Professlavl pk—
a
OWNER-BUILDER DECLARATION ! HFIJ
IherebyafBrmthatlamexempl fromthe CDmraciors Limnse Lawforthe SPCCW CUI LSC
0o 3 IV
following reason.(Section 70115,Business and Professions Code:Any dty or
OZI"'u9 countywhichrequiresapermlttomvtma,altepimpmve,demolish,orrcpair TEMP. OR['OLE INST.
Fhi .'ri anystmcturepdormlls lswance,aborequlrcstheapplicant foreuch perentlo
RATR
0 Ole a signed statement that he b licensed pursuant to the provisions of the OWER DEVICES
Oss Contractor's License Law(Chapter 9(mmmenelog with Section 7000)of Divi- SWIMNIIING POOL ELECTRIC
BOJ sion3ofthe Buslnessand Pro!emiomCode)orthatheiaexemptthemfmmand VALUATION
E9 x...3333 the basis for the alleged exemption. Any violation of Section 7031.5 by any _
65
applicant for.permitsubjects the applicant to a civil penshy of net more than OUTLETSFS
SWITCHFIXTURES Ja`
6
ofive hundred dollars(5500). NEW RESIDENTIAL ELECTR C ✓✓
GGG777 F-11,as owner of the property,or my employees with wages as thele cols SQ'�' STORIES E CONSTRUCTION
compensation,will do the work and the structure is not intended or offered for
O sale(See.70K Business and Professions Code:The Contractors License Law
B does not apply to an owner of property who Wilds or improves thereon,and OCC.CROUP RFS UNITS
who does such work himself orthraugh hisoweemployees,provided that such
improvements arc not Intended mattered forsale.If,however,the building or TOT :;-a
Improvement B,sold within one yearofcompidion,the owner-bullderwlll have
tlae rdenotLeaving that he did not Wild or Improve for purpose of sale.). QTY,' PLUMBING PERMIT FEE17ppDZONE APN
"L as owner of the property,am exclusively contracting with licensed
contractors to mostmct the project(Sec.7014 Businessand Profeaskens Code: PFRMITISSUANCE ..a
The Contractor's License law dues not apply to an to of property who ALTER-DRAIN It VENT-WATER(EA)
Wilds or Imprnbca thereon,and who contractsfor such ptujects with a
,Il{(+darts)licensed pursuant to the Contredoe.License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
L�I am exempt under Sec B&P C for thin mason
DRAINS FLOG ROOF, SANITARY Y N_
Owner Date R AREA,GOND' RECEr"Y
WORKMAN COMPENSATION DECLARATION
III®I hereby affirm that I have a certificate of consent to self-insure,ora H%TIJRES PER TRAP SCI100L TA% Y_ N_RFGQPf N
certificate of Workem'Compevation Insurance or a unified ropy thereof(Sec. GAS EA.SYSTEM-1 INCA OII7LET5 �� PARK IT2 Y N
3800,Lab Cd
Polity X/JJL7aL+ (g•Jg z- y RECEErN
Com Pte— CASEA,SYSTEM-OVER4UA)
,�PanY a d�A,{LL{,f/11F iayt BUILDING DTVI. ON FEES
Hifi dopy ere i,hed. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FE•E a\ EaC
Candied copy Is filed with the city Inspection division. I z (�s
CERTIFICATE OF EXEMPTION FROM WORK CRS' CREASE TRAP PAID
COMPENSATION INSURANCE SEV/FR- STORM-Stt1RM EA.20017. Date RCOPI t
(fhlssedi°n need not be completed B the permit I for ons hundred r
dolla
(5100)orlessJ WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I certify that o the performance of the workmanner for was towhich this p aubj c leaved,
I shall not employ any person In any manner n u to becnrrie sabject to the WATER SYSI.LM/TRRATINO
WoCompensation Lewy of California,lifornia,la, Date PAID
O Z Applicant - NEW RESIDENTIAL PLMB. SQ.FT. to Recei t#
ZO NOTICE TO MPbimtothIW.,r .'Cngthb .ti..p.ht.m.fth.L.o
shmldbecvme eubjectto the plyk t'Compeosation .,thi.p of teLabor D� TOTAL:
�FN Codgyouvoked.rthwlth romply wl[h each provision orthle pemdt shallbe B
� dmmed revoked. aass
CL CONSTRUCTION LENDING AGENCY SHIS 171d Z Ihereby affirm that there is a construction lending agency for the perform- E GT IG E
O ance of the work for which this permit is issued(Sec.3097,Civ.CJ
V Lender's Name P UMBIN ,FEE
LL I— lender.Add.. QTY. MECHANICAL PERMIT FEE MBCHA CAL FEE r�
O W Imrti(ythatl M1ave read thisappllntianaM statethattheabove ln(°rmatlon
Is mrmct.lagrceto cocounty At.......d slate laws PERMIT ISSUANCE FEES PAI
} fl mixing to building construction,and hereby authorire reprexnlatters ofthis
H Z city to enter upon the above-mentbvd property for Wpeetlon purpose. ALMORADDTOMECH.
(We)agree to save,indemnify an d keep harmless the City of Cupertino Date Recei t#
V against liabilities,judgments,mets and expenses which may in anywayar'cme AIR HANDLING UNIT 00010,000 CFM) SUBTOTAL:
ago lost send City In consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUC ONTAX
Slgvture of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCT NTAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfutum building occupant store or handle hazardous HEATING UNIT(To 100,(00m
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the Date R cc'
Health and Safety CodeSection25532(a)7 ' HEATING UNIT(OVER 100,000 BTU)
nYes M No
Will the applicant or future building occupant use equipment or devices VEMILATION FAN(SINGLE RESID) ' ISSUANCE DATE .
which cent havrdous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP QHP OR 100,000 BTU)
OiF�Y.�e T No
have read tM1eM1azar o materials rcqulrcmants under Chapter 6.95 of BOILER-COMP(OVQt 100,000 BTU) - 10
l the California Health&Saf Code,Sections 75505,25533 and 75534.1
understa ad that if the building does not currently have.tenant,that his my NEWRESIDENHALMECH. SQ.FT.
responsibility to notify the occupant of the requirements which must be men
prior to lssuanm ofa Cartificate of Ocropancy. 99
U
Owner or authorised agent Date ISSUED
' roc
OFFICE COPY