23391 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Adder.:
ro 23391 .
o _ S
one:
CITY OF CUPERTINO-BUILDING DIVISION
.+�o✓�E .t�G EC (y`j APPLICATION / PERMIT
�• BUILDINC-FLECTRICALPLUMBINGMECIIAMCAL CATEGORY CONTROL#
Architect/Engineer. Lie.N.
(/ '7 QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
MbLH
Address//�f+ i�� ' a PQtMIT IS5UANCE ❑
LICENSED CONTRACTOR'S DECLARATION L�
]hereby affirmtlut lam llcrosed underpmvWonsa(Chapter9(commemc APPLIANCESRESIDENfIALJOB a� ON
ingwithumanh BnHOn all fmcea deffeon3ofthe Bvelneseand Profmslona Code,and my SPMH
license Is In on7Ormof Diviect. PANELS
Lleend Clam Llc.#
Date Contractor —UP TO 2DO AMPS
ARCHITECT'S DECLARATION 2DI-1000 AMPS
W
Z I understand my plans shag be used as public records. OVERIOOOAMPS SQ,FT.FLOOR AREA $/SQ.FT.
O
Limned Prof naionl SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION
1i+j SPF-CIAL CIliCU1T/MISC
Z a,'�ra owingraffl.son. Natlamexempt sinesseContractor's License Law fort he
a O following which
(neap permit
o strut and Professions Code:Any city it
� ty countywhich requlrnapermit bcontvct,alter,Improve,demolish,or repair TEMP.METER OR POLE]NST. ,
'`E 7 anysttucture prior to its Issuance,also requires the applicant for uch permit to POWER DEVICES
Ole a signed statement that he is limned pursuant to the provision of the
�w Contractors License Law(Chapter 9(comrrencing with Section 7000)of Divi. SWIMMING POOL ELECTRIC< LUA �
HBO sion3 ofthe Business and Professloru CDde)orthat he6 m
exempt therefmand VAiICy't
Cab the hush(or the alteged exemption. Any violation of Section 7031.5by anl� .a
y OUTLETSSWITCHESFIXfURES DO
applicant for a permit subjects theapphcant to a civil penalty of net more than
fWundred dollars($SM.
"Lasownerofthe property, NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSIRIJCTION
�n p ari ya or my employees with wages as thele d f
compensation,wllldolhe work andthe structure la not Intended or offend for
does O die(Sec. pply to alnowandf property Code:The Contractors Llcene Law
$$ whodot such loan owner orthrouh who nem oyees,p provided tr Improves therrom,hat
and OCC.GROUP RES UNITS
whoovemuch work himself ed orough hisownemployees,providedthatouch
Improvementi arena)Intended earofredforsale.ILhowever, rider ill have
Improvement beold within oneyearofcomplelbn,theowner-bu0derwlll have
the burden of proving that he did not build or improve for purpose of sale.). Q PLUMBING PERMIT FEE
M L as owner of the property,am exclusively contracting with licensed FLOOD ZONE APN
contactors to conlruct the project(See 70K Bu,buss ami Profession fessn Code: PERMIT ISSUANCE
TheContactors License Law does not apply to an owner of property who
Wil or Improves thereon, and who contacts for such pipjects with a ALTER-DRAIN&VENT-WATER(EN
,�actor(s)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B&P C for this rcuonn11TqI IIF PITS
• Owner Date
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RECEIPT#
❑I hereby affirm that I have•certificateuc of ma
m copy
ora FLYTURFS PER TRAP SCHOOL 7A% Y N
certificate of Workeri Comperwtion Insurance as aNfled copy thereo((Sec. RECEIPT N
3800,Lab C] GAS F.A.SYSTEM-1 WC.I OUTLETS PARK FEE Y_ N_
Polity M RECEIPT#
Com an GAS EA.SYSTEM-OVER y i--\ BUI 21 'G DIVISIONFf:ES
Certified copy Is hereby furnished. GREASEANDUSTRL WASIBI EPPTOR PLANCIiECK F•£E
❑Certified copy V filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEIRN' I,-✓ ID
`I� 1
COMPENSATION INSURANCE SEWER-SAMTARY-STORM EA. .. ate Recei t#
(Thlesect(on need net be completed if the permit 0(or one hundred dollars
(5100)or less.) WATER HEATER W/VENT/ELECTR Y-2 N
I mrtlfythat N the performance ofehework forwhlch thio permit ie Wued, DA 1
I shall not employ any person in any manner m m to became subject to the WATQi SYSTEM/TRGTING
Workers'Compenation Lxwsnf Califomla. Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Revel t#
Z O NOTICE TO APPLICANT:If,after nuking this Certificate of Exemption,you
Fshould become subject to the Workeri Compenat ion provisions of the Labor TOTAL:
CC N Code,you=at forthwith comply with such provision orthls permit shall be
W j deemed revoked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d Ihembyaffirmthat there la a construction iendingagenry forthe perform- ELECTRIC FEB #
Z ance of the work for which this permit b issued(Sec.3D97,Civ.C.) - Lis ��
V O Iemiers Name PLUMBING FEE
LL F Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Imrtlfythatl havereadthbappBov
atRmaru1 statethattheabetnfmoxdIon
IL bm
cortcd.]agres to coplywlth all cityand county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>_ N relating to building construction,and hereby authariec representatives of this
Z city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH. Date Recei t#
— (We)agree to save,indemnify an d keep harmless the City of Cupertino
against llabNtiea;judg s and expenses which mayin anyway... AIR HANDLING UNIT(TO 10,000 CFM) 'SUBTOTAL:
a al In s o egranting of thiormB. AIR HANDLING UNIT(OVER IgoofiCFM) CONSTRUCTION TAX
Sigrutureof App antactor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
A7ARDOUSMATERIALSDIS S E
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
mDate Recei
aterial as defined by the Cupertino Municipal Code,Chapter 9.I2,and the
0161—
Ilcallhand SafetyCade Section25532(a)? HEATING UNIT(OVER 100,000 BTLI) TOT I
❑Yea No
Will the applicant or tum building occupant use equipment or devices VENTILATION FAN(SINGLE REBID) ISSUAN"DATE
which emit bamrdou,air contaminants as defined by the Bay Area Air Pp'+ 1
Quality Management District? BOILER-COMP OHP OR 100,DM BTU)
4 Yea N No ®p (�
havcread the hazy fety Ceeria scours 25505, 5533underaChapter.1 of BOILER-COMP(OVQt 100,000 RTU) MAR - 9 1992
the California Health building
Code,SMion25505,X573and25534.I
unponsinftytolithe tify thldingdoea nmco mcptlyhevea tenant that It Is my NEW RESIDENTIAL MECH. �.PT.
rmponibiu Issuance
of a Cthc can,of ccupaof the requlmmenta which must be met C Ur LUYCnI)iV '
prior to issuance ofaCertl(late of Occupancy. � �\)
oel
Owner or authmired agent Date I - 'ISSOE BY:_ W�
TOTAL:
OFFICE COPY �'