23811 (2) APPLICANT TO FILL IN INFORMATION WITHIN REDLINES — USE BALL POINT PEN ONLY
Building Proea Identification PERMITNO.
Building Address: 23811
666 e Ll4oYO Q.J£
ne a cense: Phone: A
Cm Y,.7*L O CITY OF CUPERTINO-BUILDING DIVISION
Conre'ao •N• ' Nm APPLICATION /PERMIT Z
0-91-4)^ GQTJ ^'a�/ �/✓RL Lk. b BUILDINGELECTRICALPLUMBINGMECHANICAL CATEGORY CONTROL
Architea[/Engineer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrene,7990, (,��QA/ -It 9S—j" PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRA R'S DECLARATION
I hereby affirm that l am licensed under provWonsofChapter 9(rommm APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwith Se n70W)ot Div dw3ofthe Buslnesand PmfessionsC„odga dmy
License Is In full force and effect. PANELS
License Clava Llc.N 7
Date Contractor
ARCHITECTS DECLARATION 201"ODO AMPS 1-ft
rez I understand my plans shall be used as public records. OVERIODOAMPS ��. S/SQ.FT.
p U Licensed Professional SIGNSELECTRICAL \ ��
J d
�.4 OWNER-BUILDER DECLARATION
i,., 1 �
1herebyaffimrthat lam exempt from the Contractors SPECNLCBtCU)T/MLSC 6
License Law for the
Wa following reason.(Section 7031.5,Business and Professions Code:Any city or TEMP.METERORPOLE INST. _ 7
counlywhlch roquiresa perrrdt to constrict,alter,improve,demolish,orrepair
a nystmummpAortoitsiaanceaTsorequkeatheappliantfwsuchp.r tt.
F O file a signed statement that he is licensed pursuant to the provisions of the POWER DEVICES a
Contractor's License law(Chapter 9(commencing with Semon 70m)of Divi- VALUATION
!4n SWIMMING POOL ELECTRIC
thebastlheBua allegess ed
exemption. Any oethat ationoseeempt70313bmand
< the bean for the alleges ezemption. Any vlolaBon of Section normo re any OUTLETS-SWITCHES O
applicant dollars mbjeatsthe applicant los dWl pensltyofna more than
flue 1,as
demo hepr(SM. NEWRESIDFNTIALELECTR SQ.FT. STORIES TYPE CONSTRUCTION
❑e a owner of the property,or my employees with wages r thele sole
C compensatlon,wBldothewarlG endthantmature is not intended or offered for -
5 p sole(Sa.7064,Bu m ae and Prole alma Code:The Contractors Lacs.Law
ns not a
does
oto an owner ofproperty who builds or improves thereon,and OCC.GROUP RFS.UNITS who does suchwork himselforthrough his own employees,provided that such
improvements are not Intended oroffered for sale.If,however,lhebuliding or TOTAL:
Improvement issmd withnomyearo(comple iogtheowner-buUderwUI have "
t"Nen of pressing that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with Licensed PERMITISSUANCE
cont dons;to constrict the protea(Sec.7061,Business and Professions Cade:
I Con motor License Law does norapply to an owner of property who ALTER-DRAIN&VENT-WATER MMbu Udo or Improve th. , and who contracts fee such ptpjects w!th e - FEE SUMMARY
c"p.ctor(e)licensed pursuant to the Cmtmdor.License Law. BACK FLOW PROTECT.DEVICE
LII am exempt under Sec. B&P C for thioc
reon
OUTSIDE FEES
DRAINS WADI,ROOF,AREA,GOND. SANITARY Y N -
. Owner Data RECEBef M
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHODLTAX Y_ N
Of hereby affirm that I have a drtlfiate of consent reel(-Inarc,ora BBC=N
certificate o(Workeri Comperstation lnsuramema drifted rvpythereof(Sec. GAS EA.SYS[EM.1 INCAOUTLET3 PARK FEE Y N
3800.Lb C.7/a O 3 7�9 91 RECEIPT N
Pollry Y GAS E.A.SYSTEM-OVER 4IRA)
Com anv 7i�ia��'%L✓� - BUILDING DIVISION FEES
MCertuied copy 6 herctiyth the city CREASE/INDUML WASTE INTERCEPTOR PLANCHECK FEE
�Ccrtlfled copy V filed with the sty Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS` GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-BAMTARY-STORM EA.200FT. Date Recei t#
(Thissectlon need nd becempleted It the permit isforone hundred dollar
($100)orlesd WATER HEATER W/VENT/ELEGTR ENERGYFEE Y_ N_
I ceri(ythat in the performandaf the work(orwhim this permit Is Issued,
I shall nm employ any pemwn In any manner coo s to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Lawn of California. Date PAID
Z Z Applicant NEW RESIDENTIAL PLMB. SQ.ET. Date Recel t#
Z NOTICE TO APPLICANIMU,after making this CenBkale of Ezemptlon,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
LCode,you=atforthwith comply with such provislom orlhis permit shall be BUILDING
FEE
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
IL Iherebyafftrm that there 6 omsrualon handing agency forthe perform- ELECTRIC FEE
n Z second the workforwhlchthb permit In lssued(Sec.3U97,Ctv.C.)
V O lender.Name PLUMBING FEE
I— Lenders Aaarcs QTY, MECHANICAL PERMIT FEE
LL MECHANICAL FEE
O W boomed.
I agretoco plywapplcityndcountty ordinances edMateatim am
IL Vmrmct.is ileeto complywilh andtyaM couhorin rnanceeand Mal slaws PERMIT ISSUANCE FEES PAID:
} W relating to build.theabtmmoryandhereby dpropauthorize reprexnpu rpo of this
H Z cltyt rater Eon the indemnify
Ices h rml inspection ttpurposes. ALTER OR ADD IU MECH. Date Receipt#
e to ve,Indemnify n d keep hamdes the ins of Cupertino
V IBties, g coria xpen whkh may In anywayacdue ALR HANDLING IJNTf(T010,000 CFM) SUBTOTAL:
a i I CI 1 n a0M anti if thio permit -
AIR HANDLING UNIT(OVER lo,Il00CFM) CONSTRUCTION TAX
5l9tturen am/ ntn m Date EKHAUST HOOD(W/DUCT). CONSTRUCTION TAX PAID:
HA R O S ERIALS DISCLOSURE
WIIII a Bcant din ocau antstore or handle hazardous I-LEATINGUNIT(TO 100,000BM
material ae deP�byt C dim Municipal Code,Chapter 9.17,and the RCCeI t#
Health aM Safety Co de Ion 75537G)7 HEATING UNIT(OVER 100,000 BTU) TOT
nYea M No
Will the applicant or future building occupant useequlpment ordeviona VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous ate contamimnts as defined by the Bay Area Air
Quality Management District? BOILER-CAMP OHPOR 100,000 BTU) P p B
Ym ❑No W
ave read the hazardous materials requlrerrents under Chapter&95 of BOILLR-COMP(OVER 100,000 BTU)
the Callfomia Health&SafetyCode,Sections 25505,25533and 25534.1 it/Af q /
understand that if the building does not currently have a tenant,that it Is my NEW RESIDENTIAL MECH. &QFT V{/I7] 1 .992
responsibility riortosIssuance of
My the onvpfOccupe rcquimments which moat be mM lyl�
prior to Lsuarcema Certificate of Occupancy. CITY lJP 1
1
Ownerorauthonaed agent Data TOTAL: ISSUEDBY: �
OFFICE COPY