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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project identification -
Building Address:
o.5 43 57zvs ce6'Lc4 -6 L V -b
PERMIT NO.
23429
wne s ante: one:
Q �o F2/C&
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDINC—MECTRICAT PLUMBINGMECFIANICAL
p
�AT tel/
(l L
C..madou.N.me: Lie ,
�G j
CATEGORY
CONTROL#
Amhlte t/Engineer. Lie. Nay
QTY ELECFRICPERMIT FEE
BUILDING PERMIT INFO
'f . C
Address: y �c j A -,I`
❑ ❑ ❑
t PFRMITISSUANCE ' 'Q
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions cf Chapter9(comment
ingwilh5 oion7000).fal lon3ofthe Busintmand PmfmionsCodgandmy
oonadgIr J Y6 P'% Jd/7 /fC-
lLice
.are
ARCHITECTS DECLARATION
I understand my plane shall be used m public records.
Licensed Profosslonal
OWNER -BUILDER DECLARATION
I hereby affirm that lam exempt fronothe Contractor's Lienee Law for the
cmntywhkh requiS lon7mttommn ss d, alt Professions Code Mydtyor
tountywhkh riortoss permitmcoorequirestheaprovgdfr ouch,ormpairmitto
anya signurepde.ment thatheegaUo sed pursuant t the inof permitto
file a signed statement that he is licensed pursuant numclog it the tion7provisions of the
Con3ofthmactoreLicense
elon3o(the Buslneseand ProfealoruCode)orthat heIs exemptthemtromand
andP apter 9 iomCom)orthathet Section and
the basis for the alleged exemption. Any violation of Section 7031.5 by any
enalty of not orethan
appucant fora permit subjects the applicant to a civil prn
five 1, as ownerdollarof
I, as owner of the Property, or he employee with wage. a thele sok
Is not Intended ormnseLoffered far
sompeec. 7044, will theworkandions Code:
sale fret. apply to a.. and f property Code: TM Contradote hem. Law
doenotsuch torkhi ..or of sWnemplayee build. or ro idedthat and
whodo=nts am not rweBorthroughhbowne. If,ho ser, the dthaing or
Improvement issold tlntendneyeared fereopered rmle. the however, deer ldingm
Improvement Iswld withinor�eyeargfcompldlory lheownerW Bderw111 have
thp*rden of proving that he did not build or Improve for purpose ofsale.),
L i L ae owner of the Property, am exclusively contracting with llansed
contractors to coetroec ct the project (S 7044, Business and Professions Code:
The Contractor's License law does not apply to an owner of property who
Wilda or Improve. thereon, and who contracts fee such p lojeda with a
c actor(s)licensed pursuant to the Contractor's License Law.
LJ I am exempt under Sec. B k P C for this reason
APPLIANCES-RESIDENTIAL
JOB DESCRIPTION
PANELS
Hv
2014000AMP5
OVER 1000 AMPS
SQ. FT. FLOOR AREA f/SQ. FT.
n 11 A D
NII
n 46
�V 9 p.U^ l E
L #.S
Y
VALUATION
SIGNS ELECTRICAL
C%
SPECIALCIRCUIT/MISCfollowing a
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
YOUTLETS-SWITCHES
NEW RESIDENTIAL ELECTR SQ.Fr,
STORIES
TYPE CONSTRICTION
TOTAL. •�
QTY. PLUMBING PERMIT FEE
OCC.GROUP
RFS. UNITS
PERMIT ISSUANCE
- -
ALTER -DRAIN k VENT (EA)
FLOOD ZONE -
'
APN
_
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
DRAINS FLOOR ROOF, AREA,COND.
pp4TQgEg PER TRAP
SANITARY Y N�
RECEIPT a
Owner Date
WORKMAN COMPENSATION DECLARATION
I hereby affirm that I have a rtlfic
[31a ate of comem to .a)(Amure, or
certificate of Worken'Compemare
atlon Insurance ma rtifled copythegf(sec.
3800 Lab )
Pollry p
Com env 7 C �i}}''OA, t,x -7:-/v
SCHOOLTAX Y_ N
RECEIPT N
GAS FA.SYSIEM-1 INC.400TLEI5
PARK FEE Y N
RGCEIFT p
GAS. EA. SYSTEM -OVER 4 (EA)
BUI LDING DIVISION PE ES
Certifi�py 6 hereby with
e ci
Certified copy Is (Ilea with thcity
e city inspection division.
CERTIFICATE OF a EMPFION FROM WORK EBS'
COMPENSATION INSURANCE
(Chia section need not be completed lithe permit Is fgrone hundred dollars
($100)or lea.')
Iartlfythat In the performance of the work for which this permit is issued,
I shall not employ any person In any manner an as to become wbjed to the
Workers'Compensation Laws of California. Date
Applicant
NOTICETO APPLICANT: $after making thIs Certificate of Exemption, you
should become subject to the Workers' Compensation provisions of the Labor
Code, you must forthwith comply with such provisions or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
Iherebyafflrm thattherels corutmdlon lending agency for the perform-
once oRhe work for which this permit Is Issued (Sec. 3097, Civ. C.)
Lcndere Name
Looder•.Addre.a
I mitlfy that I have read thisapplication and state that the above Nformation
Iscorrect. building comply with all ndtyand county thmixeonflInances
ropmseand state laws
relat oenterog to ulpont rorxsWdlon,andhereopurtyorizepectiontativea of this
city to)aree in theabnvemnify aned propertylWpectlon purposes.
(We) agree to eavG Indemnity an d keep harmiem the City of Cupertino
t said Ofty, fudgmenta, 9pmeande noes whl ma In any wa acemue
.gal said Ole. In con n .f d rating of a
/
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date ReCel t#
GRFASETRAP
SEWER SANITARY STORM EA 21157
WATER FTEATQt W/VENT/Q.ECTR
ENERGY FEE Y N
PAID
DAME Recei t#
WAITR SYSI77N/TREATING
NEW RESIDENTIAL PLMB. c'Q'�'
TOTAL:
WILDING FEE
-
SEISMIC FEE
TOTAL:
ELECTRIC FEE
,S
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID: a 4,C
D//-C(I#—(!/_ 1.
OaYe Receipt#
ALTER ORADD TO MECH.
AIR HANDLING UNIT(I010,000 CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER I D,ODDCFM)
CONSTRUCTION TAX
S
mrreo(Applcant/Contractor to
HAZARDOUS MATERIALS91SCLOSURE
Willtheapplicantorfuture building occupant store or handle haaardous
materials. defined by the Cupertino Municipal Code, Chapter 933 and the
Ilealthand Safety Cede lion 25532(a)7
❑ Yes No
Will the applicanto mire building excupant use equipment or devices
whichemit haze magus 1 ronlamimnb as defined by the Bay Area Alr
Qu Bty Mamgemtnt Diss 7
Ye o
shave read theh ous materials requirements under Chapter 6.95 of
the California Health Safety Code, Sections 75505, 25533 and 75534, I
demstend that i(thebulldin doesnot ronnly h ve a tenant, that it is my
res asibllitylonoli(ythe panto h quire o hick must met
pri tobtalanceofa I to of anry.
net or aulhgrired agent to
IXHAUSTHOOD(W /DUCT)
TI
CONSTRUCTION TAX -PAID,
-
HEATING UNIT (TO 100,ODO BTU)
-
Date RoCel [#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VJ
VENTILATION PAN (SINGLE RESID)
ISSUANCE DATE
pp�� pp
P W 1 D
iT �(](]�
MAR
'� AR x99
CITY Uh Uj't(lillVl/
ISSUED BY: l ak
BOILER-COMPOHPOR100,0UDBTU)
BORER-COMP(OVQt 100,000 BTU)
NEW RESIDENTIAL MECH. SQ.FT
' TOTAL:
OFFICE COPY