24202 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm en Identification I PI':ILWTNQ O
BuOding Addmss: - �
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�Vg L CITY OF CUPERTINO-BUILDING DIVISION
� PERMIT .
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9N°: APPLICATION /PERMIT , L"'I Ltilaaq Z
Archhect/Engineer: LM.NoBUILDING-ELECTRICAL-PLUMBING-MECHANICAL CATEGORY C 0.b+
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/' 1 �y/�-,,...�� QTY .ELECTRIC PERMIT' FEfi BUILDING PERMIT INFO
Address: ��63 S7 dk/wS �ISLVp a/cS p.
CRMITISSUA NCE a-- � ❑ ❑ ❑
LICFNS ED CONTRACTOR'S DECLARr)
ATION �
I hercby rdtormlhm lam Been•edunder
usismprovisions
and Prfessioer9de,and c APPLIANCFSRESIDENTLIL JOB DESCRIPTION
Ingwe sintpn force
effect.
Butlneseand Pro(euloneCode,and mylicen -
LimesisIns force and c.# PANELS
License Chn Lic.p
Date Contncior �s
ARCHITECT'S DECLARATION 2 i. PS
q9 2 J understand my plain shall be used as public records,. OV pPS SQ.FT.FLOOR AREA $/SQ,FT, ,I
CO
tt `j Licensed Professional SIGNSE C ' ^ I rss,
G 6 OWNER-BUILDER DECLARATION I (� •J
I hereby affirm that am exempt fromthe Contractor's License Law(o the SPEC
Fzo"' followingreason.leen inat]15, .tructand,impr vs,, Code:Anyd as,
t"' cwntywhich rcqulreaa permlttommtnn,alteplmprove,denwlieh,orr a _ TEMP. OR
anystmdure pdortp lb Wuance,abo requires theappBrant(or such perNi to
foe a signed statement that he Is licensed pursuant to the provolom of the POWER CES
3w 9(
t
Contractor.License Law(ChapercommencingwithSed1on7000)o(Divi-
O res SWIMMING POOL ELECTRIC
siothe basis fo the alnandexemption. Any)orlation f Seem therefromany ^ VALUATION
o SA the basis for the alleged exemption. Any violation of Section 7031.5 by an74 OUTLE7SSWITCHESFIXTURFS `7Z
nC"u aSX
ppliantfore permit subjects,the applicant to a civil penalty of net more than JJ �.
five hupdreddollare($500). NEW RESIDENTIAL ELGCTR STOftIFS TYPE CONSTItUC'I'ION
7,as
owner of the property, y employees g SQ'FT'
Z G p perry,or he em ur en with wages as,thele sale
com(Sce.7 on,Nations
atl ns and rk,and thestrude: le C Intended or License
�❑ axle(Sec.763y Buelnestand l'rolemlpm Code:The Contractor.Limmelaw
does not apply to an owner of property who but lids or impmvest hereon,and OCC.GROUP RES.UNTIE;
who doessuchwork him elforthrough hisawnemployees,provided that•uch O
' Improvements arc not Intended proffered for sale.If,however,thebullding or ,
Improvement le sold within oneyearofcompletlon,the owner-builderwlll have
t)1,},vrdenof provingthat he did not build orlmpron,for purpmeof•ale.). OM.I PLUMBING PERMIT FEE -
LJ FLOOD ZANE - APN
L a•owner tr the property,am exclusively Business
cos ndPro with licensed PERMIT ISSUANCE
D.Co metocomWdtheoro)ed(Sec.appy Busmenand of
Code:
The Contractor's License Law does not apply to s f°such of property who ALTER-DRAIN k VENT-WATER(EA)
Wild.t r Improves thereon, and who contracts ice such ptojests with
cq➢lTador(eexempt under amt to the Contractor's License Law. FEE SUMMARY
LJ I am exam der Sec B k P C for this reason BACK FLOW PROTECT.DEVICE
p pct nDTaIIZI: „
DRAINS FLOOR ROOF,AREA,COP SANITARY Y N
I Owner - Date RFC191'T M
a WORKMAN COMPENSATION DECLARATION rPEI�3RAla�• M1 / 5CI10OLTAX Y N
[31 hereby affi.that 1 have a certificate of consent to self-Inure br a
h ffabC lWorkan'Compematlonlmurena oracerti(Ied copythereo( RECEIPT M
c. GAS FA.SYSTEM-I INC. OUTLQ Q PARK FEE Y'
3BOON
Policy M I GAS EA.SYSTEM- (Q) sJ' REC®'1'a_
Com - t !� BUILDING DIVISIO. FEES
Llfj Certified ropy is hereby furnished. /INDUSTR x PLANCHECK PEE 7.
�I
F-1Certified copy b flied with the city impedlon division. v l /_ C
CERTIFICATE OF a EMPTION FROM WORKERS' _ GREASE TRAP PAID I 1D
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date cell tq
('this udlon need not he completed if the permit internee hundred dollen
($100)orless) WATERHEATER W/VENT/ELECTR ENERGYF� N
I certify that In the performance pf the whu
work for which this permit le ed,
I shall not employ any person In any manner ao as to become sabject to the WATER SYRI M/TREATING
Workers'Compenution Laws of Callfornla.Date PAID
z Z NOTICApplicaE NEW RESIDENTIAL PLMB._SQ.FT. ate Reuel tN
Z O NOTICE TO subiCA1.the (terrvkampering this seines pro p(En oftteLyou - _
shardou=a forth 1.the Workers'Compewtbnproallopeofthe Labor TOTA
LU N darmcd remust(orthwith comply with each provisions or permit shall be G
CL deemed revoked.
CL C CONSTRUCTION LENDING AGENCY G FEE
Ihercbya(Brmthw them bammitunssued(Sec.ion lending agency 7,Civ.r the C.) pedprnF EL RICHE
0 O anceo(theworkforwhichthh permit it Issued(Ree.3097,Civ.Cd TOTAL:
[anaert Name - PLUMBING •
LL F Lenders Address QTY. MECHANICAL PERMIT FEEMECHANICA FEE I
I certitythati have read thisappEntlonand slatelhatthe above informatio
O W n
Ucorrect.I agree to comply with all city and county ordinances and state laws I PERMITI.SSUANCE FEES PAID:
T n' relating to building construction,and hereby author n,representatives of this
H 2 city to enter upon the above-mentioned property for lrupection purposes. ALTERORADDTCMFCTL l aaa�� '
Me)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
V against liabilities,judgments,cosmand expenses which may in anywayaccue AIR HANDLING UNIT HO 10,000CFM) BTOTAL•
against said City In consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTIO TAX
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) - CONSTRUCTION AX PAID:
HAZARDOUS MATER IALS DISCLOSUR E
Will the appilcantorfuture building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Dale Cel t_q
mateilal as,defined by the Cupertino Municipal Code,Chapter 9.17,and the - _
Health and Safety CodeL5ecjlon'L5.537(a)7 HFATING UMT(OVFR 100,000 BTU)
Yee
Ill the applicant pr
future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) JSSOAWA DATE
which emit harard°u•air contaminants as defimd by the Bay Arca Air
Quality Management Dletrl BOILER-COMP OHP OR 100,0(]BTU)
Y" SEP 1.81992
'th lTEZmad the haze outmode, Salon[25505, 5533 and
of BOILER-COMP 1p0,pOp BTU)
the understand
t Health A Safety Code,Sections 2550.5,have
a t and 75534. I
understand that if building does not currently have atenanL that itle;my'
NEW RESIDENTIAL MCCIp. SQFf. /t
rmpomi ity to notity theompantotthe requirement which must CITY ser 4/UrCn+II�V
phi° ceofa nlfica
Occup ry. i1114U��\/�/\
ncr or oriad [D j/�/�/
4z It
ISSUED BY:_ie'_"I`f
OFFICE COPY