23448 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: . • - 23448
l08! s(oLleS 1{ve La er <r�o I Cts/, .
neone: - IAL DAIL
me CITY OF CUPERTINO4BUILDING DIVISION N�
Contra a Na Lie.No APPLICATION I PERMIT
LZ S Z' BUILDING-ELECTRICALI'LUMBING-MECHANICAL CATEGORY CONTROL X
Arch le /En neer. / k.No:
7 Y S �(PG2 S<dN t y/ vC_ c-Q�;.` -'t tELECi'RtC PERMITS,. P BUILDING PERMIT INFO t,�`},�,.•
'Address: </� /y, �S� . .
PERMITISSUANCE
,• • " .
/� u'l�e rT ❑ ❑ ❑
LICE,NSEDCONTRACEOR'SUGCLARATION -
Ihembyaffirmthat l am Ecansed under provlvlonsof Chapter9(commenc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwlth5efllon 7000)of DiWsion3ottheBusinessand ProfesionsC-ode,and my - �r ��y ,�c
license is in full rr�� affect. PANELS - {/` 11 R W
License Clam_�C�Gc X .37.) - 2T (
Date Contractor
ARCHITECPS DECLARATION201-1000 AMPS
N0O I understand my plans shall be used as public recnrda OVER 1000 AMPS SQ,FT.FLOOR AREA S/SQ.FT.
ILicensed Professional SIGNSELECTRICAL n�n ® '
6 OWNEReBUILDER DECLARATION. u V O T E R
In SPECIALCIRCUTT/MIS[
L., owing raffirmthatlam31.5,Bsinewaxempt from CnrrofessionsCnse Law for the
,0z following reason. 7031.5,Busln¢m and Professions Code:An city r
OGt-.� y h'° TEMP.MECQ2OR POLE INSf.
K� county rcqukeea permit tocontroci,alter,improve,demolish,orrepalr
g any structure prior to Its ismance,alsorequims the a ppllant for such permit to POWER DEVICES / Qz11
file a signed statement that he Is licensed pursuant to the provisions of the (
QQQQ6 o,G Contractor's License Law(Chapler9(mormencingwlth Section 7000)ofDivi-30 sion3otthe Bioto.and I'mesomuCode)m(hat he t exemptthercfromand SWIMMING POOL ELECTRIC ^ _
VX�ALUAft7
S the basis for the alleged exemption. Any violation of Sectio7031.5 by any I GG/
65 applicant fora permit subjects the applicant to a civil penalty of not more than OUTLETSSWITCHEs-FIXTURRS
ofive hundred dollars(SSW). - NEW RESIDENTIAL ELFCIR ,
�n ❑I,as owner of the property,or my employees with wages as that,sole' SQI r, STORIES TYPE CONSTRUCTION
C
compensation,willdothe work andthestroctum Is not Intended or offered for
Osale(Sec.70K Business and Profession Cade:The Contractors License Law
$ does not apply to an ownerof property who buildsor improve therecn,and
EE who doessuch work himself orthrough his own employees,provided that such OCC.GROUP RFS.UNITS
,
Improvement are not intended proffered for sale.If,however,thebullding or TOTAL: -
i powementt.,dwlthinoneyearofcompIMl ktheowner-bugderwilI have
t?jirden of proving that he did not build or improve for purpose of sale.), (2TY, „}+'':,'PLUMBING.P,ERMFF',r ' =FEE FIAOD ZONE APN
LJ I,as owner of the property,am exclusively contracting with licensed. PERMIT ISSUANCEmntractom m 16,construct the project(Sec.76Business a rad Professors Co :
The Contractor's License law does not apply to an owner of property who - ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improve thereon,and who contracts for such p{ojects with a'/ t•s t ,.r y,
,,15RTador(s)licensed puraosot to the Contractor's License Law. '� ),.'_ „{!r FEE'�SUMMARY',.
LI I am exempt under Sec B&P C for thin reason BACK FLOW PROTECT.DEVICE
-e Owner - Dae DRAINS FLOOR ROOF,AREA,CONTI. - SANITARY , Y_ N.
WORKMANftECEIPF X COMPENSATION DECLARATION❑ FD(TUMS:PRRTRAP SUIOOLTAX Y_ N-
1 hereby affirm that 1 have•certl0am te of consent Belt-Insure,or RECEIPT k
3800,Lab
certlflabb CJ aof Workers'Comperuatlon hsuranceoraartiflad copythereof(Sea. GAS EA.SYSTEM-11NCA OUTLETS PARK FEE Y N
Policy X DING DI X -
' Com n GAS EA.SYSTEM-OVER4(EA)
EDany BUILDING DI VISION FEES
Certified copy is heed with tlehed. GRFASE/WDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
-
ED Certified mpyt(iled with the city Inspection division. -
CERTIFICATE OF IXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWERSANIARYSTORM�EA 2DOFl, Date �Recei t#
(Thr section need not be completed lithe permit t(orone hundred tlollars
($1I nify(h WATER HEATER W/VENT/ELFCTR ENERGY FEE Y N -
I cent employ
any peomt In an thework an as to bcoom embled to theed, - —
I shall not employ any person In any manner w u to berome subject to the
WorkeraCconpereatirn,Laws of California.llornia, Data WATER SYSTEM/TREATJNG
PAID ,
z Z Appllaplicanf.
Z pNOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PCMB. SQ.Ff. Date ReCei t#
should become subject to the Worlo ri Compensation provision of the Labor TOTAL:
N
Code,you=at forthwith comply with such provielom ortht permit shall be BUILDING
j deemed revokrd. -
CL _ CONSTRUMON LENDING AGENCY SEISMIC FEE It
CL Ih¢rebyaffirmthatthem is,aconstruction lending agency for the perform,
TOTAL: ELECTRIC FEE
7 Z ante ofthe work for which this permit t twed(Sec.3097,CIv.C.)
0 O Iander's Name - E'. PLUMBING FEE
1=t Lenders Address (2iY. `•,..MECHANICAL PERMIT,'l,l ' MECHANICAL FEE
O O, I cern/y that l have read thtappliatlonand rtatethat theabove Information
tcorrect.I agree to comply with all city and county ordinance and pate laws PERMIT ISSUANCE FEES PAID:
F_ S relating to building construction,and hereby auMotl representatives ofthis
H Z city to enter upon the above-mentioned property,for lnpection purposes. ALTER OR ADD TO MECH.
_ (We)ogre¢to save,Indemnify an d keep h Mess the City of Cupertino Dere Receipt#
againtllabilitlm,pdgments,msmandex whkhmaylnanywayaccus AIR HANDLING UNIT([010,000 CFM) SUBTOTAL:
aga Id City fn uencc of the t' ofthispermit' r AIR HANDLING UNIT(OVER 1gWoctm) CONSTRUCTION TAX
r
Date IXFIAUS'C}IOOD(W/DIKT) CONSTRUCTION TAX PAID:
Sigwwrea Ilam/Contractor
HAZARDOUS MATERIALS DISCLOSURE '
Will the applicant orfutum building occupant store or handle hazardous HEATINGUNIT(TOIW,WORIU) Date RCceI t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the -
Health and Safety Code Section 25532(a)7 HEATING UNIT(OV.ER 100,0W BTU) - TOTAL:
RYea MIN.
ill building occupant see equipment or devicesVFNDLATIONFAN(SINCLERESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Arca Air e
Quality Management D❑ttrict7 BOILER-COMP DHPOR 100,000 BTU) _
4 Y's J No
havcread Healthe h
er et mode,le tions2mcntunder I 5533anhapter6.95of BOILER-COMP(G1 100,000 BTU) PAID
the eratanm la Health building the Safety Code,Sectionntly h ve.terad 25534. I
respontand that notifytheodoee not therequirement
have a ten ant that It is my h)Ew RFSIDFNTIAL MECH. SQ.FT.
priors Issuance
nfa Ceheompantotpancy.irementswhich must be met /1R 2 d 19J
prior to issuance ofa Certificate of Occupancy. � � n L�
Owner or authorized agent
TOTAL: ISSUE])BY:�U
OFFICE COPY /