23797 (2) i APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro M Identip¢tion PERMIT NC).
BuW ing Addrm - L-OT S 23797
_rod G-Raos�� c�t��t�
rex. in dO.vf11
233-%06 CnY OF CUPERTINO-BUILDING DIVISION
Contntm'a Name APPLICATION I PERMIT L
Kaj '^ BU LDINGELK'IRICALPLUMBING ML HANICAL CATEGORY COMIROL N
kee/Englrmec .
BUILDING PERMIT INFO
e Q ELECIIUCPERMFr - FEE
43,
. a (_ PFRh4'1'ISSUANCE -^— a
ICENSED CONTRACTOR5 DECLARATION L(J
[hereby tfbm thutlem lkmxd undo providxu of Chapter9(mmmen APPLIANCES-RESIDENTIAL JOB DE'CRLPHON
ingwlth Smt n7V00)of Div1,1m3ofthe Butl and Pmfessl Code, dmy
[item.b In fullf dLICN effect 33 PANELS
j LI¢ xa, __
nClaS�wc�
Date 1.1c.1 or
UP TO 2DO ANUS
ARCHITECT c - 201-1000 AMT'S
92 7undeeMaM rr7 pion.Mollis.urd upubkc remrdu OVERIOOOAMIS SQ.FT.FLOOR AREA S/SQ.FT.
CO
(� L)¢rmed Pmfn,bnal SIGNS ELECTRICAL1 ^ st)4 -
OWNER-BULDER DECLARATION Ct' 4 1 hereby affirm tham Contractor'.tI aexempt from the Contor'.Llex.Law fee the SPFLIAL CItCUrT/MLSC
0 9 following recon.(Seaton 70315,Bushes.ant Profedona Cade Any city orI}]s'3.MIFCFR OR POLE IN
I r„ e� county whleh requira permit to eurmtrut,alter,lmprwe demolish,or replr T
�4 any rtr m prior to lb bvame,alw requ�the applicant for such permit to
G`o Rle a signed Yatement Out he b Itonex d pun Cant to the pmvdlorm of the POWER DEVICES
Q6 Con actm' L{cerme Law(Chapter9(mmmenMgMilt Seton 7000)ofDM-
I 3�e slon3ofthe Buainem and Pmfeub¢Code)orthrthebexempttheefmm.M SVI34UNG POOL C VALUATION oG
tk boats for the alleged exemption. Any violation of Section 70715 by any - ry
r applleam fora permit wbteta theappliant too civil pevhy of one more than O HES-FDnURES iV �• _��
r� five hundred da11a.(55M.
z� n 1,u owrer of the prop nty,or my employm olth wages u th it wle NEkR*FNTLAL ELFCLR STORIES TYPE CON'MUCUON
mmpenat on,wiflclothr work,andthe structure b rot intended or offend for
O ale(Sec 70K Bu,lrcv and Prnf.imm Code:The Contactor.Urerme Law
til S� docs not apply to an ownerof propertywho bWlda orimproves thenor,and OCC.GROUP REB.IJNRS
whodoeseuchworkhlmaelf¢t gh M,ownemployees,pevdedthatsuch
Improvements are not Intended oroffernl fexr le.If,however,the building mdidI
Improvement baold with:norcyearofcompletbn,thewmer-buWerwlll have -
t rden of prorina that he dnae wild or improve for purpue of sale.). QTy. PLUMBING PERMIT FEE
"1,to,owner of the property,am exclusively mntractng with li¢n,ed FLOOD ZONE APN
oontator to ostrut the pm*d(Sec.70M,Businem and Prvfeabm Code: PFRMR ISSUANCE . .
The CoMntor'a Lion a Law clan not apply to an owner W property who ALTER-DRAIN&VENT-WA=TA)
Wilde or improve domene,�and who mrrcnaa for,ueh PPje ta with a - -
gLt(act Bre pursuant to the Cantratora Ll¢ra,Law. FEE SUMMARY
c LJ 1 am exempt under Sec B&P C for this reason BACK FLOW PROTECT.DEVICE
ORAINSH.ODR ROOF,AREA CONTI. SANITARY Y_ N—
Owncr DateRFCEII'f N
�I WORIGIAN COMPENSATION DECLARATION
❑I hereby affirm that I have a rertlRate,M ocownt to sell-Iwre,or a FD(nJRES PER TRAP SCHOOL FAX Y N_
I mrtl(1¢tem(Workm'Campematlmlvunn¢xa¢nl(led mpythereof pec. - RECEIFT .
`}(I 39W,Iab C) GAS EA.SYSTEM-1I ,icfu TLEIS PARKME Y N
I aky N GAS FA.SYSTEM-OVER d(EA) RFCFlPf N
m Y �1LBUILDWG DMSION FEES ..
CertNed ropy b filed hereby
the eLty CREASE/INDUSIRL WASTE INTERCEPTOR PLA➢'IC+ry,.�(
CartNed mpybfl4d with the city lmpeabn dlvialon. IVB Iv(L�JC� ` _—
l CERTIFICATE OF EXEMPTION FROM WORKERS S'A'SE TRAP pAlp
COMPFNSATIONWSURANCE sLWElHSANTfARY siORM EA.2ofIFT Date Recei t#
CThor cation need n¢be eunplted Ilthe permit b(more hundred dollen
($1w)
IWATFRHEATm W/VENT/ELEC7R ENERGYFEE Y_ 'N
¢rtky that In the petamwmof New¢k/arwhleliWspsmde blawed, —
I,hall nx employ any p¢rwn N any manner w u m become,ub)et to the WATERSYSIE✓./TREATING
O AooBran Compenatbn law,of California.Date PAID
'Z0 NOTICE TO AI'MICANT':H,after making this Certificate of Exemption,you NEW RESIDENTIAL FLMB. SQFT. Date Re i t#
N should became,ub)tct to the Worker'Compeuttlon provbbu ofthe Labor TAL:
Code,you most forthwhh mmplywlth ouch provbios,or this permit shall be G
W j deemed!rroked. SEISMIC FEE
CONSIAlKT10N LENDING AGENCYI.
aZ IherabyaBbm thtthmre ammtautionker ,gageryfortWFerfomr ELECTRIC FEE
7 Z .no,of the work for which thin permit la hared Chen'.3097,CW.C.)f PLUMBING FEE fJ 0 Lender.Name
LL F- Leeder.Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I¢rtifythrtlhx,,,nxdlhisapphcatbnaM statethtthe.boveinfmmaicn
1 bmrreci.lagreelocomplywkhaBdtyandmuntyoniln.nm dYUf m PFRMITISSUANCE FEES PAID:
} N relating to Wilding mnrtrutlon,and hereby authorize representatNnofthb
F Z city to enter upon the awrr
ve- entio¢d property f¢Inspetlon purpo,ea. ALTERORADDTOMECH. Date Revel t#
— (We)agree to ave,indemnify an d keep harm].»the City of Cupertino AIR HANDLING UNIT - P
agalrert Welee,pdgmew,mrta and expense w k,h may ft,.ywayaovue (TO 10,000 CFM) SUBTOTA
aga Wt,aid City in..,.quer¢of the gaming otthis penNt.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTLONTAX
I!Y Signature of Applicant/Cmdracter Date. FXFIAUST HOOD(W/DUCD - CONSTRUCT NTX j'.i /'mat.
HAIARDOUSMATERIALSDlS SURE IfE11. lQu�` �^ cp—
Wlllthe.ppliaut¢future wilding oavpant.t.m.r handle hazardous HEATING UNITOC,100,030 BTU) Date ei
material as defir M by the Cupertino Municipal Code,Chapter 9.12,and the
Ho.lthard Safety 75532(.)? I-DATING IJMT(OVER 100,000 BTU)
❑Ye, No
Will the a pplican�re bulldirgamrpam use equlpment or d ewe, VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
hkh emit hazard it mntm3ruMeu deOred by the Bay Area Air p
Quality Managemexri Mel BOR.EIZ-CVMP PHPOR1011.0()O BTl1) P M D
4 Yn IC3 No
l luvoread lhehav oily Cosdr,Sb touirem0S,25 and 2553x.1 of BOILER-COMP(OVERIW,000 BLV)
the CelOomla Elealth&Safety Code.Setloms 25505,75533 and 75539.[ rJ UN 28 1994
rMenibd slut ifthewOd p .ft mrrren hrvts tenent,that it met NEW RE9DINIIAL MEIN. SQ.FT
rnpomm011y�ntlfyth pant of the mentswhkh rrusth mea
P" ° ' a CIlY ur wrchiI
ae
Date N ISSUED BY: ►fes
fff ro
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