23235APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification
Building Address: + "_
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PERMIT NO. '
23235
. e /'(ef054o341. /^4/
CITY OF CUPERTINO-BUILDING DIVISION'•
APPLICATION / PERMIT
BUILDINGaECTRICAL-PLUMBINGMECILAMCAL
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c°no-.d°rat ane' a
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CATEGORY CONTROL N
Arc ten/Engineer. Lic. No;
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.QTY ' ,ELECTRIC PERMIT .;!'FCC ,i
BUILDINGP,ERMIT'INFO„”
Address:�, acJ Olv e—t V:sr/
tj� El L
PIRh4TISSUANCE
LICENSED CONTRACTOR'S DECLARATION
. I hereby affirm that l arelkensed under provblonsof Chapter9(commenc
Ingwlth Ee UonMM)of Dlvbion3ofthe Buslnessand Professions Cod andmy
license is in full form and effect.
APPLIANCESRESIDENTIALJOB
DFSC ON
as
PANELS
License Clpmj94 Lie If
Date y-l-uonty� �jaL
s
ARCHITECPS DECLARATION
I understa nd my pians shat 11 W used u public records.
201'1(100 AMPS
OVERI000AMPS
'SQ. ET. FLOOR AREA
$/SQ. FT,
SIGNS ELECTRICAL
Licensed Profembnal
bT[CIALCB2CUIT/MLSC
OWNER -BUILDER DECLARATION
I hereby afflrmthat l am exempt fmm the Contradors License law for the
'IPMp ME'1PR OR POL T
Ila ZU
)OWER DEVICES
SWIMM1 NG TOOL ELECTRI
following reason.(Sedlon 7031.5, Business and Profeselons Code: Any city orea
county which requ(nes a permit to corutmd, ahep Improve, demolish, Orrcpalr
any structure prior to its Issuance, also requires the applicant for such permit to
file a signed statement that he b licensed pursuant to the provolone of the
Ce trader's License Law (Chapter9(commencing with Section 7") of Divi--
earn 3 of the Business and Professions Code) or that he b exempttherefrom and
'
Peas,
VALUATION
the baso for the alleged exemption. Any violation of Section 7031.5 by any
the me ore than
applicant for ipermit subjeMm
OUTLET SSWITCHFSFI%TURFS
.
�'—
O VV '
_
NEW RESIDENTIAL ELFGTR SQ.Ff.
rive hundred dollars ($500).
❑ I, as owner of the property, Or my employees with wages as their sole
ORIF
TYPE CONSTRUCTION
compensation, wiildothe work and the structure b not Intended or offered for
.1. (See. 70K Business sad Professions Code: The Contractors License law
-
s..-
_
does not apply to an owner of property who builds or Improves thereon, and
does such work himself or through his own employees, provided that such
OCC. GROUT'
RHS. UNITS
improvements are not Intended Oroffered forsals. If, however, thebuilding or
improvement osoidwithlnoneyearofcompleim,lhe owner-bullderw111 have
TOTAL:
`
the urden of proving that he did not build or improve for purpose of sale.).
u I, as owner of the property, am exclusively contracting with licensed
mntractom to construct the projed(Sec. 7044, Business and Pro(cmiom Code:
QTY. PLUMBINGTERMIT`",i�,' 1 FE$'
- ISSUANCE
PSH .�
F1AOD ZONE -
APN
'
The Contradors License Law does not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such pd
tojes with a
W=x0or(s)Ilcenaed pursuant to the Contractor's License Law.BACK
LJ I am exempt under Sec. B k P C for this reason
ALTER -DRAIN di VENT- WATER (EA)
-
FLOW PROTECT. DEVICE
'IjjS
'FEESUMMARY•
DRAINS FLOOR ROOF, AREA, COND.
FIXTURES PER TRAP
SANITARY Y - N
RECEIPT N
Owner Date
WORK MAN COMPENSATION DECLARATION
hereby affirm that I have a certificate of to
SCHOOLTAX Y_ N
,❑ consent eel( -Insure, ora
certificate Of Workers' Compensation Insurance candfled ropy thereof (See.
3800, Lab C )
Policy
Co- myAnY .✓
RECEIPT M
GAS F.A. SYSTEM -I INCA OUILM-
PARK FIE Y - N
Rmr=
GAS F.A.SYSTEM-OVFRd(FA)
BUILDING DIV] E[S
iLSJ�artlfied copy b hereby furnished. city /
Certi(led copy o flied with the city Wpedlon division.
CREASEANDUSTRL WASTE INTERCEPTOR
PLAN FEB / 1
—1
CRFASETRAP
' CERTIFICATE OF EXEMPFION FROMWORKERS'
COMPENSATION INSURANCE
RFls sedlodneed nct becompleted if the permit o(Or one hundred dollars
(Q
PAID
Da[e RCcei t#
'
SEWER -SANITARY -STORM EA. 2011rr.
(SIM)or less.)
I certify that N the performance of the work forwhich this permit Is owed,
WATER HEATER W/VENT/ELECTR �
ENERGY FEE -Y N
I shall not employ any person In any tanner su as m beromc subjed to the
Workerti Compensation Laws of California. Data
WATER SYSTEM/TREATING
PAID
Applicant
NOTICE TO APPLICANT: If, after making this Certlfiate of Exemption, you
should become subject to the Workerd Compeaatlon provlslons Of the Labor
Code, you =at fort hwith comply with such pmvolom or this permit shall be
deemed revoked.
Recei ted
NEW RESIDENTIAL PLMB. SQ.FT.
-
TOTAL: "
BUT
-
_
SEISMIC FCE
CONSTRUCTION LENDING AGENCY
Ihereby efftrm that there b a mmtadlon lend Ing agency for the perform-
arm of the work for which this permit is issued (Sec. 3097, Civ. C.)
D
ELECTRIC FEE '
- -, ., ,., ISE ,
QTY. �� MECHANICAL'PERMIT'` i'
PLUMBING FEE
Leader's Name'.
Lenders Address'
I certify that have read thbappOcationand statethat theabove Information
is corned. I agree to comply with all cltyand county ordinances and state laws
MECHANICAL FEE
PERMITISSUANCE
FEES PAID: -
relating to building construction, and hereby authorlee representatives Of thb
city to enter upon the aboveennotioned property for inspection purposes,
(W a c to save, Indemnify an keep harmiem the Clot Cupertino
ALTERORADDTOMECH.
Date eeei til
P
ruga la labllBio,jrdgments, costsan expenses hlch may In any weyacwe''
against IV City mneryuenre of grants dthls permit
-- —3d '9
AIR HANDLING UNIT l0,W0 CFM)
- '
S TOTAL:
AIR HANDLING UNIT (OVER 10, 000 CFM)
CONSTRUCTION AX
a rco(Appllant/Cont nor Date,
EXI IAUST I TODD(W/DUCT)
CONSTRUCTION AX PAID:
HAZARDOUS MAT .RIALS DISCLOSURE
BEATING UNIT (TO 100,000 BTU)
Wlllthe applicant or future buildingoccupant store orhandle hacardous'
material., defined by the Cupertino Murddp.l Code, Chapter9.IZ and the
Date' ccs fl
'Health and SafetyCader�Saedlon 25532(.)7
❑ Yes u N°
TING UNIT (OVER 100,000 BTU)
•1•
VE FILATION FAN (SINGLE REBID)
1$$UANGE DATE
Will the applicant or future building occupant iseequipereet ordevens
which emit havardou. a I, etarnart. as defined by the Bay Area Air
BOILFR-COMP DHPOR 100,000 BTU)
Quality Management Disldd7
Yes j❑'� No
I have read the hazardous materials requirerrcnb under Chapter 6.95 of
the California Health k Safety Cods, Sections 25505, 25533 and 25534. I
PAID
Ir K
'
ROfLER-COAIP(OVER 103,000 BTU)
-
NEW RESIDENTIAL MSCI 1. SQdrf�A�
understand that tfthe building does not currently have a tenant, that It is my
30
responsibility to act(fy the occupant of the requirements which must be met
199
Oi�
prior to Issuance of a Certificate of Occupancy.
ISSUED
Owner or authmirrd agent Date
TOTAL: "
OFFICE COPY