23999 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification - PERMITNO.
Bulding Address: 23999
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1L' MA0 tJ1O .+tJ ` 0' '-J63_x.66'7 CITY OF CUPERTINO-BUILDING DIVISION
Contractors Name: Lie.No: APPLICATION I PERMIT Z
Architect/Enginee r Lie No: BUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL#
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE � � ❑ ❑
LICENSED CONTR under provisions
I MhSyiotr that IOOD)of visimsedheBusirovlandPmfhmsr9(comdm AI'I'LIANC[SRFSIDENTIAL JOB DESCKB'I'ION
IngwBh Section force and
fthe Busiussand ProfesslonsCade,end my
license is in full force and lee# PANFlS
License Class Lk.p
Date Contractor
ARCHITECTS DECLARATION 201-1000 AMPS
00 I understand my plans shall be used u public records OVER 100D AMPS SQ.FF.FLOOR AREA $/SQ.FT.
90� Licensed Profeuimal SIGNSELECTRICAL
6 OWNER-BUILDER DECLARATION SPECIALCERCUIT/MISC
1 hereby.M.that I am exempt from the Contraeorb License Law for the12
following reason.(Section 7031.5,Business and Professions Code:My city or TAMP.METER OR POLE INST.
P� t� cmntywhichrequimapermittomwtrvd,altepimpm ,demolbh,orrepalr
.a anystrutture prior to its Lvuance,atso requiriatheappliant for such permit to POWER DE VICES
file a signed statement that he is licensed pursuant to the provisions of the
,u,t� ContnRor's License Law(Chapter 9(mnurencing with Section 7000)of Divi- SWIMMING I00L ELE
F,�05 elan 3 of the Budneas and ProfesslonsCode)or that he is exempt therefrom and VALUATION
S;' the basis(or the alleged exemption. Any violation of Section 7011-5 by any
apph.rt fora permit subjects theapplkant to a civil penalty of not more than OUTLETS -IFSH
e. five hundred dollars($500). NEW RESIDENTIAL ELECTR
..�n ❑I,as owner of the property,or my employees with wage as their sole .FE STORI FAN
ONSTRUCTION
C7a
compensati
on,erof othe hepmprk,and rty,or yemplreis not eswthended oroffered for
$�❑ vie(&c.7Wy 8uslneas and Protesslov Cotle:The Contracmla Llrerue law
S$ does net apply to an owner of pmperty who builds or improves thermq and
who doessuch work himself or through his own employees,provided that such OCC.GROUP NITS
improvements are not Intended or offered for sale.If,however,the building or OT
Improvement is sold within one yearofeemple fts,the owner-builderwill have
t�E�uben of proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT � FEE FLOOD7DNE
LJ L as awner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec 7044,Business and Professions Code
The Contractor's License Law does not apply to an owner of property who ALTER DRAW&VFM WATER
Wilds or Improves themes,and who contracts for such p(ojects with a (EAI
Cut ar exempt
underuac.to the Contractors License Law. BACK FLAW PROTECT.DEVICE FEE SUMMARY
Cut am exempt under Sec e k P C for this mason
• Owner ES
Date DRAINS FLOOR ROOP,AREA.CONTI. SANITARY RECEIPT=.
WORKMAN COMPENSATION DECLARATION FE(TUR8S�TRAP SagOOLTAX Y_ N
❑I hereby affirm that I have o Insurance
a c of consent to copy thereof
or a
3800,Lab o(Worken'Compensatlon Insurance m a rertifkd copythem�f 45ec. RECEIPT#
38110,Isis C3 GAS EA.SYSTEM-1 WC.p OUTLETS PARK FEE Y N
Polley p RECEIPT`#
Com any GAS EA.SYSIFM-0VER4(EA) BUILDING DIVISION FEES
CerOfied copy la hereby tum
❑CertNed copy V(Red with thea city city inspection division. GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK PEE
CERTIFICATE OF E'XEM"ION FROM WOR KERS' GREASETRAP PAID
COMPENSATION INSURANCE
(Thissecilonneed not becompletediftheperndt isforone hundred dollars SEWER-SANITARY-STORM EA.200FT. Date Recei t#
(S10 mdtfyth WATER HFATFRW/VENT/ELECTR ENERGY FEE Y N_
1 artily that o the performance oltbe work to as tob this become
Is issued,
I shag not employ any person In any manner so ss m become subject to the
O golicant mpewtion Lawa o(Califomla.Date WATER SYSTEM/TRGTING PAID
-
z 0 NSI7CE TO APPLICANT:If,after making this Certificate of Em ption,you NEWRESIDEN]IALPLMB._SQFI'. Date Recei t#
should become subject to the Workers'Compensation provisions of the Labor
P
W Cade,you most forthwith comply with such pnevbloru mthis permit shall be TOTAL:
W > deemed revoked. B ILDNG 'E
CONSTRUCTION LENDING AGENCY
a O I hereby affirm that there b acomtruction lendingagenry,forthe perform SEISMIC FEE
O an097
e,of the work for which this permit is issued(Sec.3 ,Civ.C.) TOTAL: ELECTRIC FEE
O Leader.Name PLUMBING FEE
LL F Lender§Address QTY. MECHANICAL PERMIT
O w IcertifythatIhsvemadthisappliationandstatethattheaboveinformation FEB MECHANICAL FEE
d is correct.I agree to comply with all city and county ordinances and state laws PERMITISSUANCE FEES PAID:
% relating to building construction,and hereby authorize representatives fthis
1— Z city to enter upon t above-roxntioned property for Inspection purposes. ALTERORADDTUMECH.
— (We)agree to dernnify an d keep harerdess the City of Cupertino Dale Receipt#
agaWt abllitles, d cossand expenses which may In anywayaccrus AIR HANDLING UNIT(TO 10,(00 CFM)
agar said City ce of the grantmg%f this permit. SUBTOTAL:
AIR HANDLING UNIT(OVER IQ"Cr.M) CONSTRUCTION TAX
Signature of App HAZARDOUS MATERIALS DISCLOSURE Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAU
Will the applica fit or future building occupant store or hand le hazardous HEATING UNIT(TO 100,ODOBTU)
material as defined by the Cupertino Municipal Cod,Chapter 9.1 Z and the Date
He❑altY�d Safety Code,SclnJioon 2S532GRCeei t#
)7 HEATING UNIT(OVER 100,000 BTU)
❑ TOTAL:
Will the appeont or nature Wilding cecapant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE ATE
emit hazardous a I,eontaI
min.ins as defined by the Bay Area Air pz Lf
Qua lily Management District? BOILER-COMP OHP OR 100,000 BTU) +AN
Yes Q❑No
haveread the hazardO. materials requirements underChapter6.95 of BOILFR-COMP(OVER 100,000 BTU) JUL 21 1992
the California Health k Safety Code,Stolons 25505,25533 and 75534. I
understand that lithe building does not curnntly have a tenant,that it is my NEWRE%DENTIALMECH. SQ.FT
responsibility to notify the occupant of the regWremenrs which most be root /s
prior to issuance o(a Cortlflcate of Occupancy. CI I Y UI- UUt-c n 1 114V
Ownero innitirized agent Date
TOTAL: ISSUED BY:C/
OFFICE COPY