23506 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pealed Identification PERMIT NO.
Build Ing Add a.:
le� a�31 �SCa15cLn Dr 23506
n ante:
Plume: •.
1� A
'. LDUCa-'n' - docker- c�5a-036?1 CITY OF CUPERTINO.BUILDING DIVISION •��yy ��yy
Cnntrador'c Name: Lie.No: APPLICATION / PERMIT —1�"lZ
_ BUILDINGEC
-ELTRICAL PLUMBINGMECHANICAL CATEGORY CONTROL M
Architect/Engleeer. Lie.N.
lj:B,UILDING'PERMITjNF0,
- QTY'` a t.. ELECTRIC PERMIT)1,t t .''yi PEE
Address PERMITISSUANCE ❑ 1:1 El. LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licenced under provisions of Cha pier 9(comndic APPLIANCESRESIDENTIAL JOB DESCRITION
'ngwith Section 7000)ofDivlsion 3 ofthe Business and Professions Code,and my • _
license is In full forte and effect. PANELS
License Classa
Date 'Contractor lip TO 2DO AMPS _
ARCHITECTS DECLARATION ?<I7"1000 AMPS
m0O I understand my plans shall be used as public records. - OVER 1000 AMPS '' ,n`� FT $/SQ.ET.
�qq�!! CC r -Y VRr�I
k z Uku Licensed Professional. - SIGNSELECTRICAL P'.0
<FA OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MLSC
Ihercby alfirmthatlamexempt lromthe Contractor'sLlcenselawforthe
oo following reason.(Section 7031.5,Business and Professions Code:Any city orTI'.V7P.MECQt OR POLE INST.
P / �aA
OZt"'u9 ntywhichmquiresapermittommt Malterimpmve,demolbh,ormpalr
`� ,'ri c aey.tructura prior to its evicance,alsorequiras theappllcant forsuch permit to 1
POWER DEVICES
file a signed statement that he is licensed pursuant to the provisions of the
}EE}((Ow Contractor's License Law(Chapter 9(commencing with Section 700D)of Divi-
F�OQ sion3 ofthe Buslnesaand Pb IM
rofsesIona Code)or that heexempt therefrom and - SWIMMING POOL ELECTRIC - -
VALUATION
6.•a1 the basis for the alleged exemption. Any violation of Section 70315 by any OU7LETSSWITCFIFSF7XTURES
ot m
applicant for a permit subjectsthe applicant to a civil penalty of nare than
o ve ndred dollars(Sfi00). - 'NEWRESIDENTIALELECTR
eawner al the property, c'Q.ET• 570WE5 TYPECONSTRUCTION
p perty,or my employee with wage as their sale co peneatlon,wllldothe work,andthe structure is not intended or offered for
Osea •(Sec.7044,Business and Professions Code:The Contractors License Law
PjS don not apply to an owner of property who Wilds or improves thenen,and OCC.CROIIP RFS[WITS
EE who doessuchwork hlmelforthrwgh hisoweemployns,provided that such
Improvements are not Intended orofferedfor sale.If,however,thebuilding or
impswementissold within oneyearofcompldiogtheowner-builderwill have s
- th�rdeno( mvin that he did not Wildmire rovefur u olsale.). �', t'_ t't i ."I[E','
p R p pinnae QTY. ;,I!SUMBINC�PERMIT•,_t, FLOOD ZONE ArN
4 as owner of the property;am exclusively Business
and
dProwith licensed PERM ISSUANCE
Tu,Contra ro ronalmnse Law project apply70414, to nemand a property,
,who
The s or Imor's s the Law aces not apply to an owner p property who ALTER DRAW&VENT WATER(EA) .
ce1t a tr lmprwn thence,and who contracts for such paajects with a °•i•' ,TEE`SUMMARY ' ry
m,}1LL<�Iador exempt
dnder Setmthe Contractor's License Law. - BACK FLOW PROTECT.DEVICE
LJ I em exempt under sec. B &P C for this reason '
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
OUTSIDEFIES
Owner - Date R[CEITN
WORKMAN COMPENSATION DECLARATION FIX'TVRES PER TRAP SCHOOL TAX Y N_
01 hereby affirm that I have a certificate of consent to xIf4.xure or a RECEIPT M
certificate ofWorkeri Compensation insurance ora certified copy thereof(Sec. GAS EA.SYSTEM-1 WC4 CUTE, PARK= Y N
3800,Lab C.)
RECEIPT#
Policy p GAS G.sY5ITNE.OVER 4(FA)
Com Ceany - BUILDING DIVISION FEES
r1nified'copy Is hereby furnished. CREASE/INDUSFRL WASTE INTERCEPTOR PLANCI-IGCK FEE
Certified copy is filed with the city,inspection division. _
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP - - PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.XIOfrI'. DBIe Receipt#
(Thissedion need nor be completed If the permit Is forone hundred dollars
(11m)mInes.) - WATER}{EATER W/VENT/E7.ECTR ENERGY PEE Y N.
Iccrtify that In the performance ofthe work for which this permit la issued,
I shall not employ any person in any manner w u Io become subject to the WATER SYS7FM/TRFATIN'G
Workers'Compensation laws of California. Date PAID '
0 Applicant - - NEW RES7DENTfAL Pf.M B.� SQFT. Date Recei t#
Z O N0710E TO APPLICANT:IS after making this Certificate of Fxemptinn,you
ana,la bemme.ubject to the worker;comperuanon prowbru Dries Labor TOTAL:
LU N Code,you must forthwith comply with such provisions orchis permit shall be
W
5 deemed revoked. MILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC PEE
CL I hercbyaffirmthat them Lsdmmtrudlon lendingagcnry,for the perform- - TOTAL: ELECTRIC PEE
Z seen-of the work for which this permit is Issued(Sec.3097,Civ,G
O O Landers Name PLUMBINGFEE
I- Lender.Addreas - QTY. MECHANICAL'PERMIT ' ' 'FEE,
LL - - MECHANICAL FEE
O W s,, meet.cerlifIagrebaveread ply is with allcityndcoutyordina abovedformation
S rerormct. Wildine tog
complywo ,anll dhereb auhmian repreadnces and&ain softhie I'FRMTTISSUANCE PEES PAID:
reytoenterulPongmmove-nnnandhereby authorizepectiontativnofthis - 0-
N dry(We)
ree to the ee,Indemnify an
property for Inspection Ireof Cupar ALTER OR ADD TO MECH. '
Z - (We)agree to save,Indemnify an d keep harmlm the City of Cupertino - Date, RBCCIJ3t#
V. against liabilities,udgemets,coal.and expenses which may in any wayaccrue AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL:
agairuI ciCltyinconsequenceofthe granting ofthls permit.
AIR FIANDLING UNIT(OVER Ift"CFM) CONSTRUCTION TAX
Bike fvm ofA c t/Contractor Data EXHAUST HODD(W/DUCT) CONSTRUCTION TAX PAID: _
HAZ R DOUS MATER IALS DISCLOSER E
Will the appllcant or future building occupant store or handle hazardous EfEATING UNIT CED 100,000 BTU) Date - RCCeI I
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
lies lth and Safety Code Section 75537(a)? HEATING UNIT(OVER 100,000 BIT 'TOT
Ye .�,No - r
Willtheappllcant or future building occupant use equipment rdevices VENRLATION FAN(SINGLE RESID) ISSUANCE DATE
- which emit hazardous air ont.mnanls as defined by the Bay Area Air
lity Management District? BOILER-COMP OHP OR 100,000 BTU)
Q5 Yaa. Pic No
have read the haze us materials requirements under Chapter 6.95 o!' ' BOILER-COMP(OVI32100,000BN)' 'p� A
the California I lealth&safety Code,Sections 75505,25533 and 25SM.�1 V
understand that lfthe building does not cameelly have a tenant,that it Is my NEW RESIDENTIAL MECIL SQ.FT. ' /J pa�� ^
responsibility to notify the occupant m
pant of the requirements which must be et 4
priorlolssuanceofaCeitifimteof Occupancy. , R7
99�
Owner or authorired agent Date - ISSUED BY:
OTAL:
OFFICE COPY..