23259 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildingPrn'ee Identification - PERMIT NO.
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Building Address: 4 ba r2an�on a- 23259
wntr, ant��e: l nI<eeFa� A
MaJ6TTY OF CUPERTINO-BUILDING DIVISION
co- "•^� APPLICATION / PERMIT 6 [
BUILDINGELFCTRICAL PLUMBING-MECHAMCAL CATEGORY CONTROL a
Architert/hesiluem Lk.No:
QTY - ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions o(Chapter9(commenc APPLIANCERESIDENTIAL )OIDESQXR-HON
...c.hBectf°nl_.Divtion3o t eBuslnema dPr9feWone Code,andm
IM TO 200 AMS
Iimme I3in lu —dlect.' /_ PANELS
Lkensc Clam k.N1-�
Det Contractor C� 101-t000AMPS F{
Cdl heuS ON. T T , V
NO Zpq (understand myptm shaRbe used apubllcremrde. OVER IOW AMPS R 5/SQ.Fi.
(1 Licensed I'mfemiaml SIGNS ELECTRICAL Ct
«< m OWNER-BUILDER DECLARATION P I E R
fi,a SPFCIALCIXCUIT/M
z p"81 owing asorenthat n.(Swm7031 ,B fromossa d Profieor'e Licemelaw(ar the
po
following mason.(Swim 70315,Business and Profemkna Code:Any ctty or
op 9;:
a countywhich requires a permittomrutmct,alter,Improve,demolbh,°`repair �MP.METEROR EINSf, ��/ ��
g`a anytructure prlorto its a nurs
rM
ance,alaorequamthe appliramfouch pe POWER DEW ATE a
K1 file a signed statement that he is licensed pursuant to the provisions of the
3wContra ors Lkeme Law(Chapter 9(mmeencingwith Section 70W)ofDivi.
SWNIh11NG LFIECTRIC
�0 don3 of the Business and ProfemioneCode)orthat he is exempttherefromand VALUATION
the basis for the alleged exemption. Any violation of Section 70315 by any 01177-E WIIC}iP$F7%7'URFS
ya0C"c applicant for a permit.ubjectm
sthe applicant to a civil penalty of not ore than
five hundred dollars
erofthepro NE ESIDENTIAL ELECTR STORIES TYPE CONSTRUCTION
jjj �I,as eaowner of the property,or my employees with wage• r their sale �'�'
C � mpenaatlon,will dothe work and the awcturetnet intended or offered for
$'�O sale(Sec 704q Busteaa and Profemlom Code The Contractors License Law
does not apply to an owner of property,who builds or lmprovm thereon and OCC.GROUP RES.UNITS
CC whod.assuchw°rk hiceselforthrough hi•own employees,provided that such
improvements are not intended orof(ered(orsale.If,however,the buildingor TOTAL:
Improvement Issold withinoneyearofcompletion,lhe owner-bullderwlll have
tl� rden of proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT ' FLOOD ZONE APN
Ll L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCEcentracton to construct the Eel(See.7014,Business and prolamines Code:
The Contractors License Taw does ata apply to an owner of property who ALTER-DRAIN&VGNT-WATER(FA)
Wilds or Improves thereon, and who centracts for such pm cea with e
n actor(.)licensed pursuant to the Contract°r.License Law. BACK Flow rRorper.DEVICE FEE SUMMARY
LJ I am exempt under Sec B k P C for this reason
DRAINS.FLOOR ROOF,AREA,LION SAMTARY Y NOUTSIDI�Owner Date RECEIPTI _
WORKMAN COMPIiNSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N
hereby affbrn that 1 have o lean ate of consent d self-insure,ora RhTHPI'N
ce (late o/Worken'Compematlonlmuan oraartified ypy thereof(Sec. GAS EA.SYSIEM-11NCA ETS PARK FEE Y_ N
3S Lad,C.) �1 7QI /f
Co n LI '7�I L/ GAS EA.SY5TFM-OV (EA) RECEE'fp
Y l BUILDING DIVISION VRIiS
�CenlRedcopy ie furnished. CREASE/WDUSIR ASIS INTERCEPTOR PLANCHECKFEE
erlNed mpy Is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWERSA Ymichf EA IOOFI Date Recei l#
(Chis cession need not W permit((the per [V(crone hundred dollen
($140)or1y th pertheworkforwhichthispermitI.hoord, WATER TFR W/VENT/ELECTR ENERGYFEE Y_ N
I sha0 not employ any person In any manner ao as to become subject to the 1VA YSTEM/TREATING
Workern Compensation Laws of California. Date PAID
O Z ApplicantfterkingCertificate RESIDENTIAL PLMB. SQ.FT. Date Revel t#
ZO NOTICE esubJettothe orke saCompethisationpoo(ExempHe Labor
shoulyb =sefbhwl°the plyMt Compema tomo thop o the Labor TOTAL:
N domed
inked. hwith comply with each provlslom ortht permit shall be
j deemed mvokcd. BUILDING
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE
M Iherebyafflrm that there is a comtmetion lending agency for the perform- ELECTRIC FEE
Z ...of the work for which this permit is tsuad(Sec.3097,Civ.C.) TOTAL: -
U O Lmder••Name PLUMBING FEE
ly I— Iander.Addrem QTY. MECHANICAL PERMIT -E ECHANICAL FEE
O W Icertitythatlhave rcadthbappllmtlonandatatethattheaboveinformation 1 ;PAID:Iscoreact.l agree to comply withal)chyand county ordinances and state laws / PERMIT ISSUANCE FEES PAID;relating tobullding mostructlon,and herebyauthommeapresenttivesofthusZ cityWaidsrupontheabove-mentioned propertyfertspectlon purpose•. ALTER OR ADD TO MFCH.
agree to saveIndenWfy an d keep harMem the Ity a/Cupertino DatC Ragal at a 1 %jadgments,coats ends penace which may) anyw yaccme AIR HANDLING UNIT(TO 10,000 CFM) SUBago t 1 o u fthc anting of this t AIR HANDLING IINTT(OVER l0,000CFM) CONSTRUCTION TSignature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION THAMRDOUS MATERIALS DISCLOSURE
Will the appucant orfuture building occupant store or handle hazardous HEATING UNIT(TO 1W,000 BTU) Date R
material as defined by the Cupertino Municipal Code,Chapter 9.11,and the
I lealth and Safety Code Section 25S31(a), HEATING UNIT(OVER I00,000 BTU, "' TOTAL: i
YeaNo
Willihea ppilanl or tare building occupant use equipment or devices VENTILATION FAN(SINGLE REBID) 1$g�1 ArAlgE®ATE
which emit harardom air contaMm em as deflated by the Bay Area Air Y AYE
Q1ualality Management D❑isMct, BOILER-COMP OHP OR 100,IXp BTU) �a
4 Yes d No C
have .i.Hh.hazar ommat`,Sl di.0 25505,uD3e Chap(e4. I of BOILER-COMP(OVfiR 100,0IXI BTU) MAR 1992
understand Health building
Safety Code,Section15505,ve a tenant,
that. (
understand that lithe the occupant not eraquire have which that It trey NEW RESIDENTIAL MEIN. SQ.W
`mor to ility toIssuance
nfafytheocte of cof cupa requirement which most be`ret CITY jr l/Urtrtil)'1V
prior(°Issuance of Certificate of Ocmpanry, �—a
Owner or authorized agent Data
TOTAL: ISSUED BY�_�µk
OFFICE COPY