23210 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Build ingA/res: rol 0 VEr 23210
rare ams: one;
U )53'j CITY OF CUPERTINO-BUILDING DIVISION /
• C r dor' Name: •/ -Uc.N. APPLICATION / PERMIT ( _
U �,4 P7 BUIL.DING-ELMTMCAL�PLUMBINGMECHAMCAL CATEGORY CONTROL M
A Itect Engineer. Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
ACdress PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ihemb affim that l are licensed under provisions ofChapter APPLIANCFSRESIDENTAL
]OB OESCRBTION
Inerac isi.fu 7000)o(Dlvidon3ofthe BudnessandPro(mlonaCode,and ,w^�
IlrenIs le in fu f andeffect. R S O y PANELS V a'
License Chea k.tl 7'J �
Date - Contrader /(OMd (.
ARCHITECPS DECLARATION 201-1000 AMPS
µof reO Zp I understand my plane stall be used as public records. OVER I ODO AMPS SQ.FT.FLOOR AREA I /SQ.FT.
Ed� Licensed Professional SIGNS ELECTRICAL q E D
<«Q OWNERex exempt
(m DECLARATION •� r
Z�< �, LawSPECIALC6lC[RT/M15C T-IN�\/I �1 C
Theresson.(haton 7031m frmnthe Contractors License Any fort he Y
op following reason.(Section 70115,Business and Professions Code:My city or
O Z s. TEMP.METER OR POLE INST.
county hichcture riortoss pemdt tomro truct,alter,requires the
applicant for
to 2 Qf
any atmduretaemethsuhe I.licerequ pursuant
revisions of the pp6yER DEVICES / �"---
Q file a signed dor's Wam eLa that to h Banged pursuant to the ion 700ra of the J'
Contractor's Lkeme Lw(Chapter9(rommendng with Sectionherefof and
r"G+ SWIMMING IDOL ELECTRIC
SOS
Wonbasis for
thealle ed Pmfmion. Any orthrt he Is exempt there(mm and VALUATION
6
the basis for thealleged exemption. Any to a civil
of Section 701L5by reany OUTLETSSWITCHFSFD(TURFS
IT hundfor.prMt SM. the applicant tea dull perulty dnot more than
Ov Laso demodollarIhepro
�I,as owner of the property, NEW RESEJENTIAL ELECTR SQ.FT, STORIES TYPE CONSTRUCTION
�n p orl ya or my employee with wages r their sole
t compwaation,B.Mmthework andthe etsdurehnoHntShied or offered for
O don net apply 7066,to a1nower of property
Co Wilds or impctofs Llcerae Law
$ does nossuclt man unser ofpropedywhonemporlmprwvidedes eoMand OCC.GROUP RES UMTS
E6 who doeaeuchworkMmeendedorough hleowne.If,however,
prwWedlharg or
Improvementsarenotintendedoro((ec (oreah.ILh ew deer ldingve TOTAL;
Improvement 19sold withinoneyvawlcomplctbmtheowner-builderwlll have
try9�m en of proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD WASTE APN
LJ Las owner of the Properly,am exclusively contracting with licensed PERMIT ISSUANCE
.'Le m,tod 64,B
wsulruthe pmject(Sec.70uslne®and Pefenima Code: ,S
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN DRAIN k VENT WATER(EA)
builds or improves thereon, and who contracts for such plu"with a FEE SUMMARY
cod
rogaor(s)licensed pursuant to the Contradors License Law. BACK FLOW PROTECT.DEVICE
L-iI am exempt under Sec. 0 k P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner - Date RECmTtl
_ WORKMAN COMPENSATION DECLARATION FD(TURFS PER TRAP SCHOOLTA)( Y_ N_
I hereby ork that I have a Imumne of consent to self-Insure,(Sa RIKA=N
certificate o(Worken'Cemperaatlen lruurance oracertl(kd copy thereof(Sec. GAS FA.SYSTEM-1 INC-4 OUTLETS PARK FTE Y N
3300,Ieb CJ �� RECEIPT
Pollry Y� GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
Go
any j
Celli a copy h hercbytumc1ty
�Certkled ropy h filed with the dty inspection division. GREASE/INDUSML WASTE INTERCEPTOR PLANCHECKFEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASE7RAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA.MOFT. Date 'Recei t#
(This section need not becompleted if the permit Isfor°ne hundred dollars
(IlMorlee.) WATER HEATER W/VENT/ELECTRENERGY FEE Y N
Imrtify that In the performance of the work for which this permit ie lased, • 3 0
I shall not employ any perm In any manner s as to become subject to 1M
WATERSYSTEM/TRGTIN'G
Werkers'Compen9aUon laws of California.Dace PAID
Z Z Applicant RESIDENDAL PLMB. SQ.FT. Date Reeel t#
O NOTICE TO APPLICANT;$ making
after this Certificate of Exemption,you
should become subject to the Workers'Compematlon provisions of the Labor TOTAL:
N Code,you moat forthwith comply with such provisions orthb permlt shall be BUILDING
W > deemedrev.kcd.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Iherebyaffirm that there h a construction lendingagency for the performs ELECTRIC FEE
Z arm aflhc work(or whkh this permit hLesed(Sec 3097,Civ. TOTAL:C.) ZZ-
_0U O Leedera Name PLUMBING FEE z
LL I— Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I cerHfythat I haveread thhapplicatlonand statethattheabove ln(omati°n
1 lacorred.l agree to complywilh all cityand rountyordinances and elate laws PERMIT ISSUANCE FEES PAID:
N relating to building construction,and hereby authorize representatives ofthh
H Z city to enter upon the above-mentioned property for inspection purposes. ALTFROR ADD TO MECH. Date Recei t#
V Me)agree to save,Indemnify an d keep harmless the City of Cu pert Inca P
aga Wtilabilitics dgme s,exdsande.pensee whl hmaylnanywayacems AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL;
a i d qty roe sen thtga ng of le pertnit.
—�, Iz�1�l� AIRHANDLING UNTT(OVER1gWOCFM) CONSTRUCTION TAX
'igvmre of AppBca /Contractor Data EXHAUST HOOD MIDUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or forces building occupant stare or hand Is hazardous HEATING UNIT(TO 100,W0 BTU) Date Recd t#
matertal as defined by the Cu Eno Municipal Code,Chapter 9.12,and the
Flealthand SafetyCoca Seyl6n 25533W7 HEATING UNIT(OVER IOgWO BTU) TOTAL:
Yen No
Ill the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE BESIDE ISSUANCE DATE
which emlt hazardous air cents Mmnts as defined by the Bay Area Air
� �iallty Management Distrl BOILER-COMP OtIP OR 100,0BTU)9 BTT A ' D
4 Y29 0
have read the Fazar ous materials requirements underChapter GER
95 of BOIL -COMP(OVER 1 00,000 BTU)
the California Hsalthk SafetyCode,Sediom25505,2SU3aed2S534.1 JAN 29 1992
understand that ifthe building does not sh rrently have a tenant,that it my NEW RESIDENTIAL MEIN. SQ.Ff
responsibility to not Ely the span of the requirenrnts which swat be rest
Prior tonce aced °cope /1;29-9d
G I Y�Ur r,UPthfuYU
Owner or aul erimd Elgent �� Date ISSUED BY: a O LL
TOTAL:
OFFICE COPY