23515 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building project Identification
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Budin�ddreu�j : [" PERMIT NO.
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23515
APPLICATIO I IAL DAM
Rav uE.L.Er _ CITY OF CUPERTINO-BUILDING DIVISION _
con ctar'.Name: _ Lk.Nm APPLICATION If PERMIT
4rIeS �L/rsI SON gU LDING-E ECTR CAL PLUMBINGMEC4 AMCAL CATEGORY CONTROL#
rchiteet/Engineer. Lk.No: 3
LN CSN` ' eo' QLY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addros: te! �- `�. eery°j�
I'ERMITISSUANCE ,/��
LH
LICENSED CONTRACTOR'S DECLARATION
I hereby affirmthat l am Ikensed under Provldonsof Chapter 9(comucco APPLIANCES RESIDENTIAL .JOB DESC N
in8`th&e on7000)ofDlWsim3ofthe Businemand PmfemionsCodgmd my
license I.In fou form and elect. - PANELS
.
LimneeC as saes# J,z g
Date Contractorrava
ARCHITECT' RATION 201-10DOAMPS J/
^0 CZO I understand my pbmu shall be used u public records.' OVER IOW AMPS SQ.FT.FLOOR AREA $M.FT.
PEEddill d 1, Licensed Pmfeplovl SIGNSELECTRICALIV
G- OWNER-BUILDER DECLARATION SPECGLCIRCf11T/M1SC
Z y. I hereby afflrmthat I am exempt fromthe Commerce.License Law for the J��
O OL F rn following reawn.(Section Tall S,Businessand PmfmiOm Code:Any city or /
p� .G7J countywhkhmquimapermlttomrotrucyalter,impmw,demolbh,orrepair �P.METER OR POLE INST.
y < anystmctum Prlort0lbismame,alnoreWu theappgcantforsuchpermltto POWER DEVICES
K U Ik a stgnad statement that he is Ikensed pursuant to the provbiom of the
3rj Contractors License LAW(Chapter 9(commencing with SeRbn 7000)of Divi- SWIMMING ft70L ELECTRIC
eton3ofthe Budomand PrafessbmuCode)orthathebcumpl thercfromend / VALUA]]ONd O
she basis n for the alleged jemathea. Any violation of Seaton cm by any OUTLETSSWITCHFSFIXTURPS Z (l •--a ®®
appliant(ora permit aubjectetheapplkanttoativll penaltyof na more than ( C
LasOwner ll of property,ormyemployeeswith Wages or
NEW RESIDENTIAL ELFCTR_SQ}T. STORIES 'TYPE CONSTRUCTION ,
Compensstlon,Business ahe nd
and lhes Code:Th not Intended or m.L for /
O vie(Sec apply to abieas el f pmpc ty Code The Contractors LIcave Law
�?a; does not apply to w ownel of pro ugh his
Who Wilds
wnempor improm,idedrmR and
such
who doasuch w .&meelorthrough hleow;ae.lf yee;pr,theb ildingor OCC.GROUP RFS lWT15
improvementsarenot Intendedprofferedforeak.If,however, Elder Wingor T
improvement b wld within one ycaro(campletloM the owner-mgderwill have
tIA-Ilunlen of pmving that he did net build or Improve for purpose ofxk.), QTy, PLUMBING PERMIT FEE
LJ L as owner of the property,am exclusively contracting with Ikensed FT.00DZONE APN
contractors to construe the project(Sec,70K Business and Professions Code: PERMIT ISSUANCE
The Commerce.Lt..Law does na apply to an owner d property Who
Wilds or Improves thereon, and who contacts Ice such Ptojecta wfth a ALTER-DRAW&VENT-WATER(EA7
o�R[�actor(s)licensed pursuant to the Contractor's Lim..Law. FEE SUMMARY
I_J I am exempt under Sea B&P C for this reason BACK FLAW PROTECT.DEVICE
EEES
• Owner nate DRAINS FLOOR ROOF,AREA,COND. OA IJAKY Y N
WORKMAN COMPENSATION DECLARATION RECEPI'k
QI hereby affirm that I have•oertlfiam of consent to self-Ince,or FIXTURES'PER TRAP SCHOOL TA% Y N
aeilateofWorkerd CemPevanon lrsursna cracartlfled mpythereoffSec. - RECEIVE It
3800,olicyN CJ GAS EA.MrEM•I INCA OUTLETS PARK FEE Y_ N—
Co
RECEIPT#
Com any GAS-EA.SYSI'Eht-OV[iRdIRA) BUILDING DIVISION FEES
�CenNed copy V hereby furnished.
�Certified copy bfiled With the city Inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE VrZ
CERTIFICATE OF I%EM PTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Thissection need no becompleted ifthepermlt lsforonehundred dollars SEWERRSANTTARY-STORM FA.200FT. Date Recei tic
(Si W)orfess.) ENERGY FEE Y N
Isnot thatIn oy he my
any of he manner
kan as whichthis permit wb*dissued,the WATER HEATER W/VENT/E.FLTR �U M
1 shall not employ wy person in any nunner.t as to t=ame subject to the T e
Worlicant cam nv o(GII(pmis.Date _ L WATEpSY'"1Fl1/LRE171NG PAID �/V' 767E
0 Applicant� �.
Z 0 NOTICE 7u7(PPLTCANT:lf,aftermakingthb Ceeifkate of Exemptlon,yw NEWRESIDENLIALPLMB. SQjrE Date Recei t#
N should become subject to the Workers'Compensatlon pm,,il.m of the Labor TOTAL: s
Code,you resat forthwith comply With such provialos orthbi perms shall be IS
LU j deemed revoked. ' U O O
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby a(firmthat there b a construction lending agency for the perform. !FEES
RIC FEE
Z ana ofthework forwhlch this permit b issued(See 309'/,CIv.C.) �+
V O Lenders Name PLUMBING FEE
U. U Lend=r tAdareu QTY. MECHANICAL PERMIT FEE ANICAL FEE
O W Icenl(yshatl havereadthbapplicaln an dalatelhattheabweinfomuHm
6 iscorrect.I agree to comply with all city and county ordinances and gate laws PERMrrISSUANCE AID:
�. N relating to building comutruclon,and hereby authorize representativei of thisZ city to enter upon the above-mentioned property fm Wpection purposes. ALTER OR ADDTO MECH.(We)agree to save,Indemnify an d keep harmless the City of Cupertino te ReceitN
agaWtBablbtia,judgments,amtsandexpenvswhkhmaylnanywayam a AIR HANDLING UNIT(rO I%0DO CFM) SUBTOTAL•
against said City In comequeme of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Sig......ppucam/Contractor
HAZARDOUS MATERIALS DISCLOSURE Date IXFIAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
Will she applicant orfutme building om.pant store or handle havarcious HEATING UNIT(TO 100,000 BTU) Date
material..defined by the Cupertino Mu nitlpal Code,Chapter 9.12,and the _ Recei til
Healthand Safety Cade$e 25532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yn ,1��'fcx�n
WOlthe epplam or ram building occupant use equipment or devlas VENTILATION PAN(SINGLE RLSID) t$rjUANCE DATE
Which am
t hazardous air contaminants as defined by the Bay Area Air (mV ,
. Qu Iity Mavgement IXstrlo BOILER-COMP OFI'OR 100,000 BTM
4have read the hazy o..materials requircmenbunder Chapter6.95 of BOILFR-OOMP(OVER 100,000 BIM ry :rr
the California Health&Safdycode,Sections 25505,25533and25531, I y
understand that lfthe building dues not currently have a tenant,that it b my NE'WRESIDENTIALMECH. SQ
FT 4119 .�
mponsfbllity to notify she occupant of the requimmems which rtwat be met . •/OF.C�F Z9
priors in i euance of a Certificate of Occupancy. s/4?
Owner or authorized agent Date
.ro ISSUEDBY:
OFFICE COPY