23840 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification 77777 PERMIT NO.
Building Address: 23840
10510 DEODARA DR.
euro ante: one: A A A
F1 DDN_NENDRUKSON 255-5403 CITY OF CUPERTINO-BUILDING DIVISION
. mOrsName: LIc.N°: APPLICATION I PERMIT
VALLEY HEATING BUILDINGELECTRICAl-n MBINGMECHAMCAL CATEGORY CONTROL#
Architect/Engloar. Lic.Na.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: 1171 N. 4th ST , S J. 95112 PERhanSSUANCE EJLICINS ED CONTRACTOR'S DECLARATION
I herebd]Ill n that l ambeenaad under provislons°f Chapter9(commmc APPLIANCES.RESIDENIIAL ]OB DE effi-HQN
ingwlth Section 7000)of DiWslon3ofthe BuslnessanciPmfnsionsCode,and my
liana is In ( d effect PANELS
Lkeq.c,Cs dp
Co
Dattel_ mmcto
ARCHITECTS DECLARAfi N 201-1000 AMT'S
�X I understand my p6cis shill be tod as public mounts.
OVER]WO AMP$ SQ.FI.FLOOR AREA E/5Q.1T.
oqO
() Licensed Professional (� SIGNSELECTRICAL
OWNER-BUILDER DECLARATION $I'ECULCIRCUIT/M15C
7L, 7 thereby alarmthat l am exemptfrom the Contractors Llanse Law for the
p following reason,(Section 70315,Business and Professions Ce:Any city or
emntywhichrequi caper ttommtmd,altegimpmve,demolbh,orrepair TEMP.METER OR POLE INST.
anystructure prior to its lasvance,alsorequires theapplicint torso&permit to POWER DEVICES
C file a signed statement that he 6licensed pursuant to the provisions of the -
O� Contractors License Law(Chapmr9(cuumencingwith Section 7")of Divi- r
sion3of the Business and Pro(essiom Code)or that he 6 exempt therefromand SWIMMING IDOL ELECIRI VALUATION
!�a.•5..tt the basin for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS$WITCFiESI•I FS ; I s I i � � N_y0
applicant fora permit subjects the applicant to a civil penalty of not more than '
t" �Q five hundred delta. N. " /
l•. NEWRE4DFMIALELECTR ..SQ.Fi: � /l r�
❑I,as owner of the property,or my employee with wages r there sok - I 5 h 1 SnJR1E� e� I TYPE CONSTRUCTION
t./ mmpenaation,wllld°tM workandthestrucWre isnot lntendNor offend for
0 it i
C O si le(Sec.7064,Business and Profesoom Ce:The Contractors Limme Law
i� does not apply to an owner of property who Wilds or improves thereon,and UJA I CE
RIS.UNITS
Who does such work himself or through hisownempleyees,provided that such _
improverrants are not intended oroffered forsale.If,however,thebuilding or TOTAL:
Improvement esold within oncyearofcompldlon,the owner-builder will have
thAmrden ofpmving that he did nawnaorimproveforpurpmeofsals.). QTY. PLUMBING PERMIT FEE
LI FLOOD ZDNE APN
7,as owner tr the property,am exclusively contracting with Professions Code:
PERMITISSUANCE
TheCctoratococuwdtheproject(Sec.apply
Business and of
Code:
The Coor Imor's License law aces rad apply to an fee
of property who ALTER-DRAIN&VENT-WATER ffNN
Wild.or Improves thereon, and who mmram (a such ptojeda with a
on
,,BBII[[ ns
aruma)liceed se pursuant to the Cmor.doaa LicenLaw. BACK FLOW PROTECT.DEVICE FEE SUMMARY
L�I am exempt under Sec. B& P C for this masonOUTSIDE
GRAINS.FLOOR ROOF,AREA,COND. -SANITARY Y_ N_�
Owner Date RECEIPT N
WORK MAN COMPFm5AT10DECLARATION FIXNgEq PER TRAP - SCHOOL TAX Y_ N_
hereby affirm that I have a artifia[e of consent to self-inwre,ora RECEIPT N
rt kale o(Wmrkeri Compensatlonlnsuranaaaartlfkd ropythemof(Sec. GAS EA.SYSTEM-1 INC OUTLETS PARK .
3g W,lab C. FEE Y_ N
Policy N y GAS EA.SYSIFM.OVER 4(EA) DINGRECEDf N
C�o�m a v sr BUILDING DIVISION FEES
I1LCectified ropy 6 heed with the cit. GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
L�—J•T rtitied ropy 6 filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWFR-SANHARYSIORM EA 20011. Date Remi til
(fhection need rad be eomplmed lithe permit 6 for°rre hundred dollars
(Slaa)morless.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N
1 artily thatthe performance forwhishthis penultbooed,
1 shall not employ
person
Ie become,ono peumn n any manner so to becomsubject to the WATER SYSTFM/TREATING
Worlicant mpensatlon Laws of California.Date PAID
Q AppNOTICE
NEWRESIDENTIALPLMB. FT. Date Reml t#
Z Q NOTICE ca MPLICANThe ager ns'Co this stion pro o/Exemptionof the
,you
should humus eforth to the Workers'ComperuaHonprovbiowrethe Lab or TOTAL:
W N deemed BUILDING
forthwith rompiy with such provisions or this permit shall be BUILDING
> aamea revokes.
W
p CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there 6 a construction lending agency for the perform ELECTRIC FEE
Z ance ofthe work for which this permit 6issued(Sec.3097,Civ.Q TOTAL:
U O Ic"dere Name PLUMBING FEE
LL ~ bardersAdareaa QTY. MECHANICAL PERMIT FEE MEC14ANICAL FEE
O W 1cedlfy that l have read this application and sate that the above information
incorrect.Iagree to comply with all city and muntyerdinanasand state laws PERMIT ISSUANCE FEES PAID:
>- 0. relating to building construction,and hereby authorize representatives of thin -
F Z city to enter upon the above-mentioned property fee inspection pu rpoaes. ALTERORADDTOMFCH. Dale A2CC1 H7
— (We)agree to save,Indemnify an d keep harmless the City of Cupertino P
against liabilities,n dgmen6,cods and expenses which may In any way amme AIR HANDLING UNIT CTO 10000 CFM) SUBTOTAL:
gal t d City in sonsyuena" the a.if Soft .Permit., a �' qIR HANDLING I1h7T(OVER 10,000 CFM) CONSTRUCTION TAX
a g tarso!AppBant/Contractor D(RAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZA ROODS MATERIAL ISCLOSUR
Will theapplicant or future building mavpa storemban rdom HFATINCUMT(TC1100,000 BN) Dale Recef tis
material as defined by the Cupertino Murumpal Code,Chapter 9.12 and the
Ilellhand SaldyC e,S9ction M32(a)? HEATING UNIT(OVER 100,"BTO) TOT
❑ Yes 'm( r,No
n
Will the applicaor rebuilding occupant use equipment or devices VEJNTTLATION IAN(SINGLE RESID) ISSUANCE DATE
which emit hanrdom air mntaMnants as defined by the Bay Area Air
• Quhty Marugcmcnt tri ? BORTE
ER-COMP O 'OR 100,"BM
TU)
Yes o
have mad theh u usmaterials requlmments under Chapter 6.95 of BOILER-COMP IDQ000 BN) (,1
the California Health&Safety Code,Sections 25505,25533and 25534.1 �}+ IL/
understand that if the building does not currently have a tenant,that it b;my NEWRMDFNTIALMECH. SQ.FT.
responsibility to edify the occupant of the requirements which most be met 1
P,' uanccol a Cere fO.Panry. DEC QC)A
tiRot
1I/a Ign
n r or authorized agent ate
TOTAL: ISSUED BY: CIt .fE unV
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OFFICE COPY