23217 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prs e t Identification PERMIT NO.
Building Address:
//98 Is, 61_C1Z111V6 23217
re ante: Phone./// APPA
C S— CITY OF CUPERTINO-BUILDING DIVISION e'1 j��
Contractors Nara: ie,Nm APPLICATION / PERMIT LJ' �rl
G 1) Y; ^ I•J/'_ BUILDING-D.ECTRICAL.PLUMBING-MMliAMCAL CATEGORY CONTROL#
Architect/Englneer, He.No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:
PERMITISSUANCE ❑ El ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that lam licensed under provislonaofChapler 9(coc. APPLIANCES-RESIDENTIAL JOB DEBGRIIPI7DN
Ingwlth Sertton7000)of Divlslon3 ofthe Buslnessand ProfesucesCode,and my
license is if . �^ PANELS
Liene 1=4177kert
Date Contra C �QAM1A/ CbT `_'�
ARCHITE be
DECLARATION OVER 0 AMPSIODOAM W �La
0O Zp Ivndentand my plant dull be used"public records. ' OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
Llcenmd Profestlanal SIGNSELECTRICAL
OWNER-BUILDER DECLARATION SPECLILC1RCUIT/MISC
X f,yrA+ I hereby affirm that Is.eaemptfrom the Contractor's License Law for the
O pp following reason.(Section 7 01.5,Business and Professions Code Any city or
FZf'u9 TEMP,METER ORl'OLEINST.
countywhich requiresa permit W ourt
stru ,alter,improve,damoish,orrepair
anystmcture prlorto W fisuance,alsorequms,the applicantfor such permit to
r 5 file a signed statement that he 1s licensed pursuant to the provisions of the POWER DEVICES
3wG Contnrtor'sLicense Law(Chapter9(cemmencingwith Section 7000)of Divl- SWIMMINGPOOLELECTRIC
SOS slon3ofthe8usinessand Prate®IowCode)orthathebaam)xthercfromand VALUATION
G the bash for the alleged exemption. Any violation of Section 7031.5 by any OIJILETSSWITCIiESHXTURE$
spphant for a permitsubje Tache applicant to a civilro
penalty of not mrethan
five hundred dollars($500). NEW RESIDENTIAL ELECTR '
❑],as owner of the property, SQ.Fr. STORIES TYPE CONSTRUCTION
p prk,and the
e9eucture employees r ffelrsole
7a compensation,wllldothew Pr mdionstructurehe Contendedo icame Lfor
q sale(Sec.7Bta,Business and Professions Code:The Cantractole Llceroe Law
doe.not apply to an owner of property who Wilds or improves thereon,and OCC.GROUP HIS,UNITS
C• whodoessuchworkhlmselfathmugh Nsownempleyees,pmvldedthat.uch
improvementsam not latendedoroffered forszle.If,howevegthebuildingor TOTAL: '
improvement issoldwlthln ooeycarofcomplelbn,the owner-bullderwill have
tlVLLmrden of proving that he did not build or improve for purpose of sale.). Qjy, PLUMBING PERMIT FEE p(ppp jpNrE APN
L j L as owner of the property,am exclusively mntracting with licensed PERMIT PLUMISSUANCE
contncton to omutruct the pmject(See.7016,Business and Professions Code:
The Contractor's License Law does net apply to an owner of property who ALTER-DRAIN&VEM-WATER(EA)
Wild.or improves thereon,and who contracts for such pio)ects with
co,,11LLt..((actor(s)Licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE,SUMMARY
LJ I am exempt under See. B k P C for this reasonOUTSIDE
DRAINS FLOOR ROOF,ARRA,GOND. SANI'T'ARY Y N ,:
Owner Date RECEIPT N
f WORKMAN COMPENSATION DECLARATION PER TRAP SCHOOL TAX Y N_
zm a
hereby aBUthat I have a rtl0nrepIXgg
te of consent to.elf-Insure,ora RECEIPT N
arti(Wte o/Worken'Comp<vatlonlmsunna ananified ropythereof l5en. GAS FA.SYSTEM-11NCA OULMf PARR FEE Y N
3800,Gb CJ
Pollry X G U7Oo.J eZ - RECEIPT N
Com an C GAS PA,SYS"1'FA1-0VER4(EA)
Y BUILDING DIVISION FEES
L�Cenlfled copy 6filed
Cerlfled copy b hebhed. GREASE/NDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE
with the city impaction division.
CERTIFICATEOP INEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEINER-SANITARY-STORM EA 2oarr. Date Remi t#
(This section need not be completed if the permit V for one hundred dollars
($1(X)orless.) WATER HEATER W/VEM/ELECTR ENERGY FEE Y N
I certify that in the performance of the work for which this permit is issued, —
1.hal net employ any person in any manner so as to become.ubject to the WATER SYSTIM/TBGTING
Workers'Compensation Laws of California.Dare PAID
C) Z Applicant Dale Remi t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PCMB. SQ.IT.'
Fshould become.ubjeet to the Worker.'Compemuation provislom of the Labor TOTAL:
N Code,you mut tort hwith comply with such provisions or this perrNt shall be
> deemed revoked. _ DINQ FEE
(L G CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hembyafBrmthat there is a construction lending agency forthe perform TO ELECTRIC FEE
ance of the work for which this permit is taaund(5ec.3097,Civ.C.)
V O Lcadae.Name PLUMBING FEE _
LL 1— Lender.Addres. QTY, MECHANICAL PERMIT FEE " MECHANICAL FEE
O W a
Ini(ythatl have mad this applloHonand statethat theabovelnformatlon
iacorrert.l agree to comply with all cityand county ordinanceaand state law. PERMTTISSUANCE FEES PAID:
>. 9L relating to building construction,and hereby authmize rcpresentativesof this
I_ N city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
E (We)agme to save,Indemnify an d keep harmless the City of Cu Fenian Date Recei t#
V agaWt libllities,jticigrNrits,qpsand expenses which may In any wayacaue AIR HANDLING UNIT HO 10,000 CFM) SUBTOTAL'
against.. if ty Neo oft anon hbp Jy
oC,�7-5 AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
SI lure.(Applant/C ntractor Dale EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the apples cat or future building occu pant store or hand Is hazardous I MATING UNIT(TO 100,000 BTU)Will Re[CI t#
ma erisI as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
I le.lth and Safety Code Section 25532(.)1 HEATING UNIT(OVER 100,000 BTU) TOTA
❑Yea MN.
Will the applicant or future building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hazardousalr contaminants as defined by the Bay Area Alt S
Qu lily Management District? BOILER-COMP DEI'OR 100,000 BTU) �71
q Yes q No
haveread the hazar ou.rtuterlalsrequirementsunder Chapler6.95of BORER-COMP(OVER 100,000 LIM rsss.....�C
the California Health k Safety Code,Sections 25505,75533 and 2$534.I rG� 'I (�,
understand that lithe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.IT. 7 JC10
responsibility to notify the occupant of the requirements which must be met J�x77
prior to issuance of a Certificate of Occupancy. - CITY Uh GUrc
_ -- cal ll
Owner or authorized agent Date ISSUEDBY:V a+✓YI .
TOTAL:
OFFICE COPY