23114 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITN23114
O.
Building Address: 3 1 1 4
/, _ 3 0 (,1
Alloy / CITY OF CUPERTINO-BUILDING DIVISION A
Cont/rla,R(o/g'a Namc: / u.No: APPLICATION I PERMIT /Z-t3 D- ? /
BUILDINGM ECTMCALPLUMBING-MECHAMCAL CATEGORY CONTROL p
ArchitM/Engineer. Lk.Nee
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address:
PERMITISSUANCE ❑ ❑ ❑
LICENSEDCONTRACTOR'S DECLARATION
I hereby allirm that laam lken%d under provisions of Chapter9(mmmrnc- APPLIANC75RESIDENTAL JOB DFSCRivi UN
licenwh Semon 7000)of Divipon3o(theoupnessand ProfesslOnaCode,and m _
licenx is In fu tone and fect. .[S�as�S I'ANQS Asa U f (4 /• 14,
Licen Clan _-.1 cp cl 7 L/ VV
Date Contractor Le-
ARCHITECTSDECLARATION 201-1000AMPS
7 I understand my plans shall be used as public records JOVERIODOAMPS SQ.FT.FLOOR AREA S/SQ.FT.
COC
U Licensed Pmleswioml SIGNS ELECTRICAL
�<y OWNER-BUILDER DECLARATION
t.., 7 1herebyaffirenthat l am exempt fromthe Contreetor'sLirenselaw/orthe SPECIALCIRCUIT/MLSC
O�pq�( follm in reason.(Section 70315,Business and Professions Code:Antl or
cea
CZF'7 ntywhichrequiresapelMttocon,trun,alter,Impmve,demo h,ormpair TEMP.METER OR POLE INSI_.
ut
gy�,Qa anystrutture prlorto its issuance,also requirestheappbeantfor such permit to ..
file a signed statement that he is licensed pursuant to the provision,of the POWER DEVICES
Q 3Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi-
H O< slon3 o(the Buslnevand Pmfenlom Cods)mthat heisexemptthere(romand SWIMMING POOL ELECTRIC ~� VALUATION
the basis for the alleged exemption. Any violation of Section 7WIS by any
� 3<� fvehundforapemat$500). theappllcamtoedvilpevltyonotmorethan OUTLETS-SWITCHES
p'�FR
five hundred dollars(5500).
Q] ❑ FT
1,as owner of the property,or my employees with wages as their axle tFEEFLODDZONE
STORI' TYPE CONSTRUCTION
< compensation,wlldothewrnkand the simtture lance intended or offered for
O
Is(Sec.7044.Businessand Professlors Code:The Cci.hadoes License Law
$$ does not apply loan owner of pmperty who builds orimprovesthereoR and OCC GROIIs RFS.UNITS
who doessuchwork himselforthrough hisownemployees,prov Bird that such
Improvements are not Intended oroffered for sale.If,however,thelywh ing or
Improvement la sold within oneycerofcompletion,the owner-builderwill have
t Men of proving that he did not build or improve for purpose ofsale.). QTY. APN
Lj 1,as owner of the property,am exclusively contracting with licensed
contractors to construct the pmjsd(Sec.7044,Business and Profmlon,Code: PERMIT ISSUANCE
The Contnaor'a License Law don not apply to an owner of pmperty who a
builds or Improve thereon, and who contnm for such p0ojects with a ALTER-DRAIN&VENT-WATER WA)
m,B[Taetor(a)Icen%d puMoser to the Contractors License Law. FEF.SUMMARY
LII am exempt under Sec B k P C for this reason BACK FLOW PROTECT.DEVICE
17RIT"r-tv err,
Owner Data DRAINS FLOORROOF,AREA,COND. SANITARY Y N
r-.�
WOR KMAN COM PENSATION O ECLARATION RN
12r nercby affirm that I have a certificate of consent to sell-Insure,ce a ��S PER TRAP SCHOOL TAX V ECEII'TN
certllate of WOrkers'Comperoation In,unnce ce a certified copythereof(Sec. RECEIPT p
MID Tab C.)��L�1/�f/,�"L( GAS EA.SYSTEM-1 INCAOUTLETS PARK FTE Y N_
Company}:/yry.p a - ��--- GASEA.SYSTFM-OVER4(EA) BUILDING DIVISION FEES
rtNed copy is hereby dwith he city CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy la fled wIfu the tlty Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE $EWER SANITARY STORM EA 2WIrr. Date RCCCI t#
(Thlasectbn need not be completed If the permit lalcrone hundred dollars
(Sl W)otifyth WATERHEATERW/VENT/ELECTR17621 ENERCYFEE Y N
I certify mplo arty pformnIn an tmanner(o"tots omis eernit issubjee bmM, —
I shall not empty any pemun f any manner n as to become subjett to the WATER SYSTEM/TREATING
Worknrd Compensation laws of California. Date PAID
Z NOTICE
Applicant NEW RESIDENTIAL PLMB.
Z 0 NOulCETOAPPLICt to
Workers'
this Certificateprovisions
Exemption,you SQFT. Date Recei I#
HCode,shouloumme subjeotto the Workers'Compensation porthion,rmit the s Lab or TOTAL:
CC Uj W deemed mutt
rthwith comply with such provisions or this permit shallbu
W > aeemea reynkea. BUILDING FEE
a O CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there i a con,troction id(Sec. agency for the perform- ELECTRIC FEE
� Z once of the work for which this permit i;issued(Sec.3097,Civ.C.) TOTAL:
O O Lender's Name PLUMBING FEE
IL Lender'.Adams. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertitythatl haveread thla appBatlonand patethauheabovein(ormatlon
Is corms.l agreeto comply with all city and county ordinances and pate laws PERMIT ISSUANCE FEE PA
F N relating to building corutruction,and hereby authOmm representatives ofthis
Z city to enter upon the above-mentlonod property for inspection purposes. ALTERORADDTOMECH.
_ (We)agree to save,Indemnify an d keep harmless the City of Cu pettino Da Receipt#
against Tulles,judgments,coats an pensee which may in any aye a AIR HANDLING UNIT(TO 10,000 CFM)
ages t 'nc un of Ms It �`" SUBTOTAL:
y x gA�i l6 �l,V/h AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
niciumnne.1 Appil Data 77 EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
AZAR OUS MATERIALS DISCLOSURE
Will the applicant orfuturs building occupant store or handle hazardous HEATING UNIT(TO 100,Wo BTU)
material a a defined by the Cupertino Municipal Code,Chapter 9.IZ and the Date Reeei t#
I Iealth and Safny Code Section 25533(a)7 HEATING UNIT(OVER 10#000 BTIJ)
F1Ves M No TOTAL:
Will the applicant or(utum building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) I$$IJAN�gpATE
which emit hazardous air rom
ominants as defined by the Bay Area Air �P+' P�0 + 6J
Quality Management District? BOILER-COMP(3HP OR IKOW BTU)
Yes ❑❑No
have read the hvardousmalerials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000111 U) DEC 30 199
the Glifomla Health A Safety Code,Seniors 25505,25533 and 75534. 1
understand that if the building does not currently have a tenant,that it k M
my NEW RESIDEIALMECH. SQFF
responsibility to notify the occupant of the requirements which must be mrd
prior to Issuance of a Certificatc of Occupancy. C1 Y Ur cur tHI IIVU
Owner or authonud agent Date ISSUEDBY. Lle-4
TOTAL:
OFFICE COPY