23269 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ed Identification PERMIT NO.
Building Address: - 23269
name come: p
'4059L �S"d—�/ CITY OF CUPERTINO-BUILDING DIVISION
cent er. a Lic,Nm: APPLICATION I PERMIT ��
rchitect/En BUR.DING-ELECTRICAI.PLUMBING-MECHAMCAL CATEGORY CONTROL N
JW B Lk.Na:
QTY' ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrtsa: PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION '
Iynunderprovisions of Chapter9(mmmen APPLIANCES-RESIDENTIAL JOB DESCRIPTION
in 1thsMion7OOO)ofDiVision3oftheBusissandProfea4neCod,and my
lim..late .-
It kfaa. ;2 PANELS / ^,e
Lken `lad V- a ���� ��/
Date CHITECV//..�g0/
ARCHITECT'S DECLARATION OVER I0AMI'S
p�p�uu0ZO Iundentand my Fla.. be used as public records OVER 1000 AMPS SQ_--F1'.I�ODR S/SQ.FT.
k Licensed ProlemWvl SIGNS ELECTRICAL
dd Q OWNERexNLDER DECORATION
Ian] SPECIAL CIRCUIT/M19C
Thereby afRrmtOWNE
OWNER-xempt BUILDER
the DECLARATION
License Lwfor the .
pp following mawn.(Section 7MIS,Business and Professions Code:Any city or TEMI
Fzv'u9 countywhich requires a permit toromrutruct,alter,improve,demolish,ormpa)r P.METEROR POLE INS!. -J/I
4 a anystcture pdortolts issuance,alsorequireathe appRm
cantfor such pedtto POWER DEVICES
Igo�U Ale a signed statement that he is gamed pursuant to the provisions of the
338I� Contractors Licenealaw(Chapter9(mmmendng with Sectbn 7000)e(Divl- SWIMMING POOL ELECTRIC VALUATION
Oa+ knA3 ofthe Budnenand ProfesslomCode)orthat heb exempttherefromand
0 X the basis for the alleged exemption. Any Violation of Stolon 7031.5 by any OUTLETS SW[TCFiESHX7URES
applicant fora pemo t subjectathe applicant to•civil penalty of not more than
five C31,ashundred
owner of he pr. SQ.FT. SM ES TYPE CONSTRUCTION
$fc` NEW ftESIDENI7AL ELFGTR
�n
C3 1,as owner of the properly,or hes employees In with wage as there dole
compensation, Is not Intended or offered w
Dsale(Sec. ppy theorems Pro(esskm Code:The contractors Licensetherem Law
({ $ don not worko an owner of through his
buildsorimprovnthereo,and OCC.GROUP RES.UNITS
E
who doenuchworkhimself dedoraffe such
Improvcmente sddwJntendneyvar fcomplwle the o neer-budderwdingw TOTAL:
improverentbsoldwithlnoneyeam(complello,iheowner-bugderwlll have
tl%,�I,rden of proving that he did not build or Improve for purpose ofsale.). QTy, PLUMBING PERMIT FEE FLOOD ZONE APN -
u L as owner of the property,am exclusively=trading with licensed PERMIT ISSUANCE
mntnctmn to mmtmci the project(Sec.70ty Busmen and Professions Code:
The Contractor's License Jew don not apply to m owner of property who
W29 or Improves thereon,and who contracts for such p(ojects with a ALTER-DRAW k VENT-WATER AIA)
&or. anaed punuantto Ne Commeme'•Llanse Law. — FEE SUMMARY
V I am exempt uMer Sea B k P C for this recon BACK FLOW PROTECT.DEVICE OUTS I OF FEES
DRAINS FLOOR ROOF,AREA,RIND. SANITARY Y N
Owner Date - RECEIPT M
RKMAN COMPENSATION DECLARATION FD(TURES PER TRAP SCHOOL TAX Y N
Efrre'mby affirm that I have•certificate of consent to self-Insure,or RECF3.p N
3800llLab CI orken'Compevatlonlruurana oraakifkd mpythereo((Sn. GAS EA.SYSCFM-I INCAOUTLEl5 PARKFEE Y N
3800,Lab C.I RECEIPT N
Pam NO_Ip GAS EA.SYSTEM-OVER 4(EA)
Company (LI_p_ L BUILDING DIVISION FEES
Ce copy isfi hereby the cid. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
eki(led ropy V filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORK ERS' I GREASETRAP PAID
COMPENSATION INSURANCE SEWER- STORM-STORM EA.pUpl. Date Recei [k
(Thimu cle.need nu be completed Rthe permit b forms hundred dollen
(ft00)or aklfy trtifyt N.) WA,�I�.�W/V�,IELEC.R ENERGYFEE Y_ N_
I that the perfnsa
enof the work forwhich this permit Is owed,
I shall not employ any person in any manner sat as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Lawsof Ca Aforels.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQFr. Date Recei tM
Z 0 NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
Fshould become subject to the Workan'Compereatls provisions of the Labor TOTAL:
cc W Code,you r,wat forthwith comply with such provision or this permit ehall W BUILDING
Uj > deemed newkea.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d I hereby affirm that there isa mstruction lending agency for the perform TOTAL: ELECTRIC FEE
Z ance ofthe work for which this permit Is Issued(Sec.3097,CIv.C3
V O Lender's Name PLUMBING FEE
LL 1- U.dce.Addmss QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icertilythxtl have madthisappllnBonand extethatilmeWe.Information
IL Jammed.I.gree to cemplywilhall city and muntyordim..s and elate laws PERMIT ISSUANCE FEES PAID:
reiating to building construction,and hereby authorlu representatives of thio
tl to entero n the abovcmentiosd for inspection purposes. ALTER OR ADD TO MECH.
~ ?
city
agree save,indemnify an a keep h�mless the itypekinm Date Rmeiptif
V against liabilities,judgments,rorte and expenses which may in any wayaccroe AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL:
against mid City in mnaequence of the granting of this permit CONSTRUCTION TAX
AIR HANDLING UNIT(OVER 1DODO CITt)
Signature of Applicant/Contractor Date W LAUSr HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfumm bullding occupant store or hand le hazardous HEATING UNIT(TO 100,000 BTU) Date Recei tM
material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the
I lealth and Safety Codc Section 38)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
Yes
WIIlthe epplkant or core building occupant use equlprrent or devices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which emit hazardous air Elb�Wdcfirrd by the Bay Area Air Q
. Quallly Management District? OIR'OR 100,IXU BTU) pq
LrhaYeaID
a
ve read theFazar mus materials requirements under Chapter 6.95 of AGILE R-COMP(OVER 100,000 B11q {`� l�
the California Health k Sarad Wilding
Cod,Sections 75505,75573 and 75534.1 MAR ^ 199L
and that if the donmomently haves nant,that it my NEW RESIDENTIAL MECH. SQFT
ora Illty m notify the oc /pant oft a require vhkh must be rml: ^
I t Issuance .Certlfi !eo anry. /sl'�Y (JI, ``UI+Cf31)Is�/ (\Q J
Uwner orau/horlud agenl ate TOTAL: ISSUED BY• V{N/ 11 \�•
,
OFFICE COPY