23052 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Ruildln Pm eat Identification Ler
� PERMIT NO.
BuI1dInR Addrty,:�� � �J S 23052
+L'am7. Vince .
(AIA16 C01WENC�raS3-1531 CITY OF CUPERTINO-BUILDING DIVISION
Contractor's Nsme: ta' LIc.No APPLICATION / PERMIT
DAN CA `y—4 0 1K BNLDINGELFGTRICAL IJMB(NGMECHAMCAL CATEGORY CONr
. Architect/Engineer. Lic.Na:
i CI 4-ISIS CIC. IQTY ELE R R PGE RM
BUILDING PERMIT INFO
Add. PERMITISSUAN '
LICENSED CONTRACTOR'S DECLARATION
/hereby affm,that Ism licensed under provisions of Chapter 9(commenc APPLIANCES ENTIAL JOB DFSC ON
Ingwlth Section 70M)of Dlvblon3ofthe Rusin and ProfesslonsCodq dmy
Beams Is In full force and effect. PANELS
License Ch„
Date CControntr actor .V\ aTRY.�1`E�.\7
ARCHITECTS DECLARATION 201-1 PS
0 7. I understand my plans shall W used as public records. O 1 AM SQ.FT.FLOOR AREA S/SQ.Fr.
CO
d4,`j Licensed Profeasiorul C ELE- ^ O�
OWNERexUILDERmptfro he ContATION SPECIALCIRC / LSC L/
t..,r1A- Ihereby affirm
sm.(Sthat di.fair,701Z,B.mmthe Con.f.o Llttnselaw(or e
O... cmntyfol�win reason.(Section 7 Ito Bueinem and Pro prove, Gmeli h, d I
O z,i. B Y ty P.MREFR O LE ST.
countywMch riot tos a pemdt Loco o requi eethe applicant
p Lica tle rsuchr ir to
any.facture paler tents Issuance,also rees...I to the provisions
permit e POWER DEVICES
O � file a signed statement that he b Incensed pursuant to the provlsloru of the
Contractor's Licerax law(Chapter 9(commencing with Section 7000)of Diel-
�0 sion3 ofthe Business and Profemlo®Cede)arthat he b exempt there(romand SWIMMING 1'00 EC'1'RIC VALUATION
,-, the basis for the alleged exemption. Any violation of Section 7031.5 by any ♦ D
<� OUTLETSSWIIiFSF1XTURES
applicant for a permit subjedsthe applicant to a dell penalty of net more than
live hundred delta.($500). NEW HTSIDFNTIAL ELECTA
..�n ❑I,as owner of the property,or my employees with wages as their sole SQ'FT' STOIRIEB TYIaE CONSTRUCTION
1 C < compensation,wBldothe work andthestruenure is not intended or offered for
❑ sale(Sec.7044,Business.ed preload..Code:The Contractor's License Law
$$ does not apply to an owner of property who W m76
builds or improves Ihere,and4,�� OCC.GROUP RFS.UNITS
who does such work himself or through his own employees,provided that such
improvements are not Intended orof/ered forsale.If,however,thebuilding or TOT O
' Improvementbaald wlthineneyearofcompletion,theawnerbuilderwlll have
snofprovingthathedid not build or Improve for purpose°!sale.). QTY. PLUMBINGPERMIT FEEFLOODZONE APN
a owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
co ra ors to mrutruct the project(Sec.7044,Business and Professions Code: �.
Contractor's License Law does net apply to sn owner of property who ALTER-DRAIN&VENT-WATER(EA)
bulids or Improve thereon, and who contracts for such pRojects with a
eLl I
gqRR((ffactor(s)licensed pursuant to the Contractor's License Law. SAC](FLOW PROTECT.DEVICE OUTSIDE
SUMMARY
am exempt under Sec B&P C for thin reason
Owner DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N_
—___Date RECm'f a
WOR KMAN COMPENSATION DECLARATION
E31 hereby affirm that I have a certificate of consent to self-insure, FD('fURES PER TRAP SQi00L TAX Y N
ore RECEIPT N
380Bicateo(Workers Compevatlonlvuranttorarerti(led ropythereof(Sec. GAS EA SYSTEM-1 INCA OULETS TPARK FEE Y N
Policy
lab C.)
PoN RECEIPT N
Com any GAS S O 1 EA) BUILDING DIVISION FEES
Certified copy Is hereby te CR N U s Fr R t PLANCHECK FEE
Certified mpybfiled withh the city e dly inspection division. , ^ /s
CERTIFICATE OF O(EMPTION FROM WORKERS' GF PAID
COMPENSATION INSURANCE, SEWERS SNRM ,( Date Rete'
ITM1is.ection need not be completed If the perMt b for one hundred dollars
($100)orless.)
IcertNNbbaATTR HEATER W/VENT/ELECTR ENERGY FEE Y
ltythat the performance o(thework(orwch this permit
Issued, N_
I shall not employ any person in any manner a as to become sebfed to the WATER SYS'T'EM/TREATING
Workera Compnoutlon Laws of California.Date PAID VV1
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date R
Z O shouldNOTICWeemTO s
subject
to the
Work If,after no'Comakinparhis ationCimtl_flu/eofons oft the
Code,you bemus forth to the Workers'ComperoisinproWiomofthe Labor TOTAL:
W N deemed
comply with such provisions or this permit shall be IL was
� j deemed revoked. F _
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE on
CL Ihereby affirm that there is a construction lending agency for the perform- ELECTRIC PEE
7 Z ante of tine work(or which fhb p°rMtLs Lsaed(Sec.3097,Civ.C.) TO
(� O lander'.Name - PLUMBING FEE 7 Q
LL I— Iandae.Addm QTY. MECHANICAL PERMIT FEE ' MECHANICAL FEE
O W I ceddythatl have read thLsapplicatlonand satethatthe above Information
bcomect.lagreelo comply with all dtyand county ordinances and state lawsj PERMIT ISSUANCE PLEB PAID:
} U' relatingmbupon t comlroctlon,and herebyrtyorfor in represenpurposoftints s
L. N city toenter
ee to ave,indemnify aned keepeharrrJw the Cit purposes.Cupi. ALTER OR ADD TO MECH.
? (We)agree to save,Indemnify and keep harMem the City of Cupertino Date RCceIPI#
V
against liabilities,pdgmenta,man and expense which may In any way seems AIR}iANDUNGUNIT(TO 10,000 CFM) SUBTOTAL:
against said Cl c se :;e of the grant leg of this permit.
Y09_93 AIR HANDUNGUNIT(OVER 10,000CITU CONSTRUCTION TAX \—
a nlt�
Slgruture of Applicant/Contractor Date EXHAUSTIIOOD(W/DLJC'D CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DI SURE
Will the applicant or future building occupant store or handle hazardous HEATINGUMTGO100,000RTU) Date Race'
maleri.l a,defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
I and Safety Cade Section 25532(a)? HEATING UNIT(OVER 100,0(x)BTU) TO A
ElYes No
Will the a pplica et Met Wilding oras pant use equipment or d evlces VENDLATION FAN(SINGLE RESID) ISSUANCE DATE
which emit Farardoua air rontaMni nt,as deflned by the Bay Are.Air
Q..Ety his nagcrrcnt Dist rias? BOILER-COMP(31IP OR 100,=BTU)
I1 Vn g No
avercad theth& ety Cods,Setions 2mentsundered2SSr5.95 of BOILER-COMP(OVER 100,000 BTU) r baq
the California Health&Srlety Cotle,Sectlow 25505,25533 and 75531.I
understand that lithe building does not cumentiy have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FP. !'�❑
responsibility to notm
notify the occupant of the requirements which=at be met FEB � /,r49�s�'
prior to issuanm of a Certificate of Ocmpancy.
cit
Owner or authorlud agent Date � ISSUED BY: LU
7
OFFICE COPY