23951 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pmject Identification PERMIT NO.
ulldin Address: �y n 7L/ S /'N Cn- 23951
[Owone: / `V1•J1' A A A
TE
117 CITY OF CUPERTINO-BUILDING DIVISION _may w
cont r " L1ic �r� APPLICATION I PERMIT
QCATEGORY
(h� EDINGS.ECTRICALPLUMBINGMECtiANICAL CATEGO Y CONTROL p
rchlten neer. Lie.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address:
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION 'PIERMITISSUANCE
Ihereectionrm that)amsion3oftheorder proved onsOfChapteC(e,andm MPLIANCESRESIDENTIAL JOB DpSCRB'T(ON —
ingwllh5mlo 7000)ol DiW,ion3otthe Bu/ainessand Pmlesslom Code,and my �N�� 1^(��a,�\►f
Zaraaa IClas,I y dLl ec � J �t�irU PAN12S
Date Contractor Ir
ARCHITECTS DECLARATION 201-1000"I'S
CC' I understand my plans shall be used as public records OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
Z() Licensed Professiowl SIGNS ELECTRICAL
G�< OWNER-BUILDER DECLARATION S[rF-CIALCBtCU1T/M15C
,7t, � I hereby affirnthat lam exempt fromthe Contramrs License Law for the
pp following reason.(Scsslon 0 t to Bust and Profenkna Code:Any my
F t'W rountywhich requimapermltmromtanoud,niter,lmprove,demolth,orrepait ir 'IEMP.MECER ORPOLE INST.
'°� anysuussure prlorm its beeance,alwnqulmthe applicant for such permit to
3 F file a signed statement that he t licensed pursuant to the provisions of the POWER DEVICES
u, Contractors License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
L,� g skn3otthe Bustnessand ProfeasbroCods)orthat he b exempttheretromand VALUAT70N
the haat for the alleged ncts the n. Any violation of Se tion 703 L5 by any w IVY_
five hundred aperrs(S5 ess,theapplkant toss null penalty o(nt mom than OU'li'ET""V✓fiCtffS}7XTURFS (./va
five 1,as
of he pr. NEW RESIDENTIAL ELECTR FT.
�n ❑1,as Owner of the property, i my employees with wages as there sok _SQ.Fr. TYPE CONSTRUCTION
C < compemation,wBldess and k,and rhes Code:The
rdractIntendedoronse d for Law
D vie(Sec.7046,Bwlrmas and Professore Code:The Contrassora License law
p5� don raft apply to an owner Of property who builds Or improves thereon,and OCC.GROUP RES.UNITS
0. who does such work himself orthr°ugh hisown employees,provided that,arch
Improvement are not Intended oroltered lormk.1f,howeveq thebullding or i—
impmvement bsold within one ycarofcompletio4 the owner-budderwlll have
In,.¢urden Of proving that he did not bund or Improve for purpose of sale.). QTY. PLUMBING PERMITFEE FTAODZANE APN
U L as owner of the property,am exclusively contracting with licensed PERMIT LSSUANCE
contractors to rorotrun the project(Sec 7064,Business and Profmic rs Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VFM-WA]IIt(EA)
builds or Improves thtron,and who co rnscis for such ptojets with a FEE SUMMARY
otator(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B k P C for this reason
•
Owner Date DRAIN(+FLOOR ROOF,AREA,GOND. SANITARY Y N WOR RMAN COMPENSATION DECLARATION RFCEPTN
[:]I hereby of un,that I have a certificate of consort to self-Insure,or a FTXTUBES PER TRAP SCHOOL TAX Y N_
Mtlflute Of WOrker4 COmperuatlOn Insurance Ora cenifted copy thereof(Sec. RF-CEPT N
3800,)ab C.) GAS FA.SYSTEM-I INCA OUTLETS PARK FEE Y N
I'ollry N RECEIPT M
Com any GAS FA.SYSfEh1-OVER4(EA)
❑PCertified copythereby furnished. _ BUILDING DIVISION PEGS
❑"Rifled copy isfiled with the mSE
y inspection division. GREA /INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE
(Ihissessionneed ntbecomplted tflhepermit tforom hundred dollars SEWER-SANITARY-STORM M.200FT. Date Rec'el t#
(E100)mlev.) WATER HEATER W/VFNT/E.ECTR ENERGYFEE Y N_
I certify that o the person in anf thework so as to b ecuhis permit cbooed,
I shall not employ any person In any manner m u to become subject to the
O WATER SYSTEM/TREATING
Worcant mpen,ation laws of Calilornla. Date PAID
Z npplilian
Z NOTICE TO APPLICANT If,after making tht CertBicate Of Exemption,you NEWRESIDENTTALPLMB. SQFT. Date RettPl t#
should became subjeco the Workers'Comperuation provisions of the Labor TOTAL:
W ttCode,you must forthwith comply with such pmvlslmaorrmileall be
thta peh
W > deemed revoked. BUILDING FEE
a c CONSTRUCTION LENDING AGENCY SEISM
tIC FEE
Z
I hereby affirmthat there b a coruwnion lending agency for the perform-
anceoftheworkforwhichthtpermlttL ed(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
V O Lender,No
PLUMBING FEE
LLt- Ienaera Aaarev QTY. MECHANICAL PERMIT FEE
O W Iiscertltythatl have read thisappliation and statethatthexbovelnformation MECHANICAL FEE
4 corre .I agree to comply with all cityand county ordinances and state laws PERMITISSUANCE FEES PAID:
W relating tobullding construction,and herebyauthotre rapresentativesafthb
)— Z city to enter upon the abovcmemionei propertyfw inspection purposes. ALTER OR ADD TO MECH.
� — (We)a to save,Indemnify an d keep harmless the City Of Cu portion Date Receipt#
agaimth it lepmdgment,m ex which ylnanywayactue AIR HANDLING UNIT(To 10,0DO CFM)
again id Itylm.sryuenc oft ingotlh rrnit. SUBTOTAL,
,-1 AIR HANDLING IINIT(OVER IB000CFM) CONSTRUCTIO"Recei
n of Applicant ntrat°r Date IX1iAO5T HOOD M'/DUCp CONSTRUCTIO �—�5
Ha DOUS MATERIALS DISCLOSURE `y ,
Willtheapplicant° wmbu3dinga pantstoreorhandleha rdous HEATING UMT(I0100,000 BM l J0
material as defined byt aCupertiu0Mu,dclpal Code,Chaptsr9.17,and the Date
II❑ Yesd Safety Cade, No 25532(a)2 HEATINGUNIT(OVERIOE,OODBTU) as I r T
Will the applicant or future building occupant use equipment or device VENTILATION FAN(SINGLE it RESID) u ,
which emha,eardous air contaMwnts a,defined by the Bay Area Air I$$UANEDA2 1AN
�aQuality Mawgement Diurit7 BOILER-COMP(3tIP OR IWDM BTU) JUL J
4have Ye, Nreadthehaaa u,omaterlabrequlmmentunder Chapter6.95of BOILER.COMP(OVER]00,000 BTU) y UP
the Calilomla Health&Safety Code,Session,25505,25533 and 25534.1 GII Uf
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL mMECH. SQ.F7
responabdity to notify the occupant of the requirements which must be et
prior to issuance a a Certificate of Occupancy.
O
Owner or authomed agent pate
TOTAL: ISSUED BY:_ _
OFFICE COPY