23240 (2) APPLICANT TO FILL IN INFORMATION WITHIN REDLINES — USE BALL POINT PEN ONLY
Building Proe<t ldentlflation PERMIT NO,
Bullding Addme: 23240
z3 -!k Cu erf/ry
neve ame: one:
Sero i z 57-9GG3 CITY OF CUPERTINO BUILDING DIVISION � ^
• c°"tree .Name: CCN°: APPLICATION 1 PERMIT [�
G5 Masvn O cS• BUfLDINGELFCTRICAL-PLUMBINGMECHAMCAL CATEGORY CONTROLx
Architect/Engler.. Lk.Na
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
AdAdd. •r M/��/�L6OFW AlAle-, SJr/p S1-2S - PERMITISSUANCE
LICF.NS ED CON TRACTOR'S DECLARATION
Ihereby dfirm Nut l am licensed under prwWon.of Chapter 9(mmmen APPLIANCES-RESIDENTIAL ]OB DESCRIPTION
11 ..hSectfon 701D)of Dl effect ofthe Butivsaand ProlealondCude,and
Ilanse is In fuB and effect PANELS
Llanse As utx_39D35I -
Dale Contractor_ UP TO 2DO AMES
p(ir�r r7'1
101-1ODO AMT'S
ARCHITECTS DECLARATION
p CO I understand my plans shall be used"public record.- OVER IOW AMPS SQ.FT.FLOOR AREA S/SQ.FT.
Llansed I'rofeelovl SIGNS ELECTRICALlhomA C E D ' 1
6tkBu OWNER-R UILDER DECLARATION SPpAIAL CIl2CU[T/MISC
z baa owing raffl mthatLmexemp Proms A Contractor's Prefession,Cve Law fort be MPUTE
OO
following reason.(&esters 70315,Business ami rmfembne Code:Any sty or
717e1P.METER OR POLE INSf.
r,4 countyw etprictrwit.1...omr..q.mter,ImpmvgdemoB•h, .muttr
any atmeturc paler tettehauavgabo sed pursuant
t the revisions of to POWER DEVICES aL_,
file a actorskens statement that he t licensed pursuant it the provisions of the DAT /J_
30 dn3of,heW,ee Law(Chemlo"er 9 d,),,tingwlth Section,; lh,,fomivi.d SWIMMING POOL ELECTRIC
elon3etthe Busineeeand rrofenlons Code)orthat hebexempttheretromand
O th�basis for the alleged exemption. Any violation of Section 70315 by any OUMETSSWITCHFS IXMRBS 900/
4 appUcantfora permlbuhjeNthe applicant toativll penalty of nor mere than
flue and ed owns of
00). NEW RESIDENTIAL ELFCTR SQFT. STORIES TYPECONSTRUCTION
�n I,as owner of the Property,m my employees with wage as there door
compensation,Business
ework ansion, ode: bnot intended oroffered for
O dile(Sec 7094,t Apply rose
ox and Professions Code:The CoMtmoves Uanie Law
does�$ whodos.uthto•n ownerofpmpeh who hisme em orlmprweidedthtAnd such— OCC.GROUP RFS.UNITS
EE whodoe••uch am nor maededoaugh MdownemIf,hoeverthebuildigor
Improvements arena Intended earofc d plmiomth hoose r-budderwflI g m TOTAL:
Improvement bwld withinoneyearo(completion,theowner-builderwlll have
the burden of preving that he did not build or improve for purpose of sale.). QTy, PLUMBING PERMIT FEE
E] FLOOD TONE ArN
1,a•owner the property,am exclusively contracting ssi Raved PERMIT ISSUANCE
contractors to ronswctthewdoe snot appl70Ky
to
ProfessionsCode:
The Coor .improves,
License Law does net apply 1ct an owner d property who ALTER-DRAIN k VENT-WATER(EA)
Wilds t r Improves tpu mea,and who rontntls for such ptvjem with a FEE SUMMARY
coyB{atlor(eexempednder Seant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
LLII I am exempt under Sec. B&P C for slab reawn
DRAINS FLDOR ROOF,AREA,CONE). SANITARY Y N-
. FLES
Owner Date RECEIPT N
WORK MAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOLTAX Y_ N_
❑I hereby affirm That I lam• lmumne of consent d •pytheure,ora RECEIPT x
artiflab o(Worken'Compensatlonlnsunna ora artlfkd ropythereo((Sec. GASEA.SYSTEM4INC.4OtTILETS PARK FEE Y_ N'38 W,Gb CJ ��[[
Polley p �' ���l�I — T GAS EA.SYSTEM-OVER 4(EA) RECEUPT x
Com anBUILDING DIVISION FEES
2CertvlEed copy b bereby dwith the
city ,CREASE/INDUSFRL WASTE INTERCEPTOR PLANCHECK FEE
@Certitled copy b(fled with the lily inspection division.
CERTIFICATEOFE)CEMPTION FROM WORKERS' - CREASE TRAP PAID
COMPENSATION INSURANCE. - SEWERSANITARY
(This settle.oeed not be completed if the permit b for one hundred dollars STORM EA.Z00FT. Dale Reeei IN
($7W)orlea.) WATER HEATER W/VENT/EI.ECTR ENERGY FEE Y N
]artifythattathe performance of the week for which this Permit le blued,
I•ball not employ any person In any manner n as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation laws of California. Data PAID
O Z Applicant NEW RESIDENTIAL PCMB._SQFT. Date
eroRecel IH
Z O, N)IICETOAPPLICANT:IL•hermakingthb Certifate.f Faemptbn,you
Hshould bmesubject to the Wmiums'Compensation provisions ofthe Labor TOTAL:
CC VF Code,you mut forthwith comply with such pmWsiov orthb permit shall be
> doomed revoked. BU
WILDING
G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyafOmnthat there is a construction lending agency for the perform ELECTRIC FEE .
Z and of the workfor which this permit b Issued(Sm.3097,Civ.C.) - TOTAL
v o Lenders Name PLUMBING FEE
LL F Lceder.Addresa QTY. MECHANICAL PERMIT FEE MECHANICAL FEB
O W I adlfylhatl have read this application and statethatthe aboveinformatlon
R iscorrect.Iagreetocomply with all a
city and county ordinances and stale laws PERMIT ISSUANCE FEES PAID:
>- W relating to building construction,And herebyaulhorlae representatives ofthb
[— Z city to enter upon the abovementlomd property for Inspection purposes. ALTERORADDTOMECH. Date ReCel HI
— (We)agree to save,indemnify an d kmp harmless the City of Cupertino
agai tllabiEtics,judggmenld,roatannd expenses which may in anywayaccem AIR HANDLING UNIT(TO 10,ODO CFM) SUBTOTAL:
taxi coy Inc nciu<n in anling of this Penni AIR HANDLING UNIT(OVER I0,0D0CPhD CONSTRUCTION TAX
Signature of Applicant/Contractor Ddie EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO100,000 BTU) Date RCCCI IN
material as eleflned by the Cupertino Municipal Code,Chapter 93Z,and the
Health and Safety Code Section 75532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL
71 Yes No
Wliltheapplicamcr lure building occupant umequlpment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Qua lily Management District? BOILER-COMP OTE'OR 100,000 BTM
❑
• Yee 1 No
haveread Health
ar Pet nMedab requiremenbunder ndChapter 5.95 of BOILGR-COMP(OVER 100,000 BTU) P A I D
the understand
at if tth he building
Cods,nectbv25505,ve a Land,that I
mpomanlltyto aifythtdingdatdtcorrenttyhavk..hkngthalitbmy NEW RESIDENTIAL MEGs. SQ.Ff.
rvponsiisru..oa.C.heocae.4 Occupancy.
requlrementa which must be met JAN 30
Pala la Luuancc ofd CertlRate ofOcxvpanry. zt
Owner or authorized agent Date CITY NV l`e iT,7
TOTAL: ISSUEDBY:
OFFICE COPY