23981 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINTPEN ONLY
Buildin,Pro ed Identification PERMIT NO..
Building Address: 23981
tonere ame: /,/ oee; A
r�i9C',e -,jTf(//fZjQ.r'�,� 7f — CITY OF CUPERTINO-BUILDING DIVISION
Con �radoesName: Lie.Nm APPLICATION I PERMIT 'O�L
BUILDING-ELECTRICAI.-PLUMBING-MECHAMCAL CATEGORY CONTROL#
A Itect/Engineer. Lk.N.
_ 3 QTY ELECTRIC PERMIT' FEE BUILDING PERMIT INFO
Address: - _r
PERMITISSUANCE •/' ( '
LICENSED CONTRACTOR'S DECLARATION - 7&I
hereby aHirmthai l am licensed under provisions of Chapter 9(commenc- APPLIANCES-RESIDENTIAL Y JOB DESCRIPTION ^
Ing ith exi.id1on7000)ofd effecn3otthe Business and TrofeaelonaCode,and my II-
IicenseisinfuBI defied. !! .PANELS
License Class Llc# ea� �� '
Dare. Cantrcdor UP TO 200 AMS
ARCHITECT`S DECLARATION . 201-1000 AMPS — lvTe .VOR
ozp. Iunderstand my plans shall be used as public records.. FT
- OVERIODOAMPS SQ. .FL RAREA sm.FT.
E d(Gj Licensed I'mfembtWSIGNS ELECTRICAL 3 R
G�6 OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC 9 V ' �-
[hereby affirm thatIam exemptfrom the Contractors License Law for the V �.J
followingreason.(Sedtidn7031.5,B.tl sand Professions Code:Anydty it TEMP,METER OR POLE INST. _
�� � countywhkh rcqulresa pemNtto coratrud,alter,Improve,demolish,orrepair '
q' any structure prior m its Nuance,also requires the applicant for such permit to ppWgg DEVICES 3O�
f5 file a signed statement that he Is licensed pursuant to the provisions of the 1
pQ00u, Contradoe.License Law(Chapter 9(commencing with Section 700))ofDivi.3 O SWIdMING POOL ELECTRIC
sbn3ofthethealleged Pempticss Codeorlation f exempt th31.5by y VALUATION
the baan for the alleged exemption. Any violation a(Section 70715 by any
G�
applicant donors subjectstfie applicant too dull penalty of not more than OUILETSSWITCHESFIXTURFS ` VV
five hundred dollars( m V
' Q[,as,owner of thee pproperty,or my employees with wages as their sole NEW RESIDENTIAL ELECTR,r�SQ, O L-0 STORIES TYPE CONSTRUCTION
compensation,willdothe work andthestrudure lsnalntended or offered for
O
sale(Sec.7044,Business and Professima Code:The Contractors Llmme Law L
$ does not apply to an owner of property who Wilds or Improves thereon,and
n• whodoes such work himselforthrough his awn employees,provided that such OCC.GROUP RES.UNITS
Improvements are not Intended or offered for sale.l4 however,the Wilding or 7 /
Improvement is sold within one yearofcompldr-W
ioq the ownellderwill have I
f
tlunlen of proving that he did not build or improve for purpose of sale.). QTY, ^•PLUMBING PERMIT FEE FLOO
� D ZONE APN
u 4 as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Cade
The Contractor's License Law does not apply to an'awner of property who ALTER-DRAIN&VENT-WATER IRA)
bu11dn or Improves thereon,and who contracts for such plojeds with a FEE SUMMARY.
al5ada(s)licensed pursuant to the Contractor'sLlanse Law. BACK FLOW PROTECT.DEVICE
Ll I am saempt under Sec B &,P C for this reason_
OUTSIDE FEES
Owner DRAINS FLOOR ROOF,AREA,COND. 1 SANITARY Y_ N_
Doh RECEIPC p
WORKMAN COMPENSATION DECLARATION
Ell hereby affirm that I have a artifiate of consent to self-Insure,or a FD(TURE&PER TRAP SCHOOL TAX Y_ N—
ocrtificate
RECEIPT#
380BUbC.) orker%Comperaatlon Insurance ora certified copy[hereof(Sec. /, GAS EA.SYSTEM-1 INCAOUTLETS �1 PARKFEE Y_ N_
3500,Lab C.I l
Poikya RECEIPT#
Co ny GAS'EA.SYSTEM-OVER 4 IPA) BUILDIN DCVI ON FEES
O Certified copy Ls hereby the cid.. - GREASEANDUSTRL WASTE INTERCEPTOR PLANCHE9 F 41 ^� \ 9
Certified copy b filed with the city inspection division. /r/ j_�
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP I PA
COMPENSATION INSURANCE
(Thlssectlouneed natbecompleled ifthepermit istorone hundred dollars SEWER-SANITARY-STORM F.A.200FT. Date R
($100)m1c..) WATER HEATER W/VENT/ELECTR ENE YFEE Y Baa
I certify that In the performance of the work for which this mdt Nued, —�
I shall nm employ any person in any manner m u t the WATER SYSTEM/TREATING - PAID ( V
Workera'C ofG -
z Z ApplNOTICE NEW RESIDENTIAL PLmB..3QSQ.n. - -Date Re t#
Z O- NOTICEco P A he ahermakl mper ation pateof Exemption,you
should become subject to the Workers'Comperuatlon provlslora of the Labor TOTAL:
W 9— Code,you must forthwith comply with such provbiom or this permit shall be BUILDING
deemed revoked. ELE
M c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby afirmthat there b a mestrudlon lendlegagency for the perform TO ' ELECTRIC FEE
CJ Z Lemi.es Nwork(or which fhb permit bissued(&c.3097,CIv.C.) PLUMBING FEE
LL O- Lender's Name
LL F Lend eta Addresa - QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
0 111 IL b<tingtoagrato comply with all dtyand cothmixe ordinance an stetslawsI coitify that I have read this application and gate that the alm, et fa ton, ['FRMTTISSOANCE FEES PAID:
gelating tobuilding coratructlon,and hereby authorize represen[atives o(thb
F'- 2 city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
(We)agree to save,Indemnify an d keep harmless the City of Cupertino' - Date Receipt#
V
against liabilities,jodgments,mks and expenses which may in anywayaccme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City in mosegoena of the granting of this permit CONSTRUCTION TAX
AIR HANDLING UNIT(OVER 10,000 CFM[
Signature of Applicant/Contractor Date EIHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE Af
Will the applicant or fumm building occupant store or handle hazardous HEATING UNIT(TO 100,0DO BN) Date ReCel t#
material as defined by the Cupertino Municipal Code,Chapter 9.1Z and the
Health and Safety Code on 25532(a)7 HEATING UNIT(OVER IDO,OW BTU)
❑Yrs ,V��ej[p- -
TO
't
building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
-
which emit hazardous,air contaminants as defined by the Bay Area Air
Quality Management D' 7 - BOILER-COMP PHP OR 100,000 BTU) PAID
4Y's y[jctl0
ha Bread the bazaFd materials requirements under Chapter 6.95 of BOILER-COMP(OVER 1(0,000 BN)
the Caltemis,Health&Safety Code,Sections 25505,25533 and 25534.1 ���71 19
understand that lithe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT 1, 92
responsibility to notify the occupant of rcrrent hich must errat CITY
prior to
_� r.• _ �
Ownerorauthorbed a gent D ]$SUED BY:
OFFICE COPY.