23058 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Preen identification 7 PERMIT NO.
Building Address: n^O 5 8
X0333 �evYsvll� cx f� �uc� f;u� G3 ^J 'lI{
res ams: p r1hone:
N
.W �) U 1Jl.8prcJT 4 38• . CITY OF CUPERTINO-BUILDING DIVISION I
c°9/�'a�er's ams: LIc.N. APPLICATION / PERMIT
• A/G Nz "� ` r`�" —v BUILDINGELECTRICA-PLUMBING-MECITAMCAL CATEGORY CO Oby
ArcMEngi
ted/ nes LIc.Nm /ap
Y U,OVERIMAMPS
TRIC PERMIT FEE BUILDING PERMIT INFO
Address: J CE
LICENSED CONTRACTOR'S DICLARATION
tyl
[hereby affirm that l am licensed under provisions of Chapter9(commmSIDENITAL JOB DESCRIPTION
Ingwtth Sedim 7000of Dividm3 ofthe BusinessanciProfessionsCode,and my
license lain(uB Teres and died. �� T, -
License Class Lie p 1 F
Date Contndor
ARCHITECTS DECLARATION reO I understand my plans shall be used as public records. 5Q.FL.FLOOR AREA E/SQ.FT.
Licensed Professlotul SIGNSELEC CULT/ ' D
�<<6 OWNER-BUILDER DECLARATION SPLCIALCIRCU(T/MIST � 1V�VVV^ '
Zt"' owing asormlhatlam31.5,B(romthed Professions
License law(a the +
following reason. ices a p 7811.5,Business and Professions Code:Any city it o rt K
O �� Tf21P.METER OR POLE[NST. '\V/'
p� countywhich requlrcsa permltmrovtrun,altepimprove,demollsh,orrepair
G anystrudom pdort°its eauance,alsorequireatheappliunt forsuch permit to POWER DEVICES
/
S O 6 file a signed statement that he Is licensed pursuant to the provisions of the / 7 Z
�Qj3u, Con/norb License IAw(C)upmr9(mmmmch%withSection7W0)ofDivi-
OSR
dim 3oftheBusiness and Ptoflorse
eaeeCode)orthatheisempttherefromand SWIMMING POOL ELECTRIC
6 5 the bash for the alleged exemption. Any violation of Section dby any OUTLETSSWITCHESFIXITJRES d
applicant for a permit subjects the applicant to a civil penalty of.ot nut more
orere than �V
five hundreddnerof thepr. NEW RFSIDFIMAL ELECTR SAFE SIOIIES TYPE CONSTRUCTION
❑I,as owner will
the property,or he employees with wages offered
dole
7a compensation,wllldothe
.cd Professions;
morom Code:Tbroontractor or License
Law
M sale(See.appl00Ay
Bu sinessandf property Code:The Conrndots License Law
(/j3$ whoddoes otapplytoan rkhi owner of empilds oyeemp eithereon,and OCG GROUP RIS.UNITS
C. whodoementsa arkhimaededorugh hlsowale.lE owevrovldedthatsuch
improvements lntendncycarferedfor pictim.theower-huilderwdl gorhave TOT
Improvement beold within one yearo(compldbry the owner-bugderwill have
tFpikurdeno/proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD[DNF. APN
Lf L as owner of the property,am exclusively=trading with licensed PERM ITISSUANCE
contractors to construct the project(Sec.7044,Business and I'mmssiow Code:
The Contrador's License Law don not apply to an owner of property who
buALTER-DRAIN&VENT-
ilds or Ip..thereon,and who commexi for such ptujeces with a WATER(EM -
�'gp�ador(a)Ransed punuam to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
FEE SUMMARY
LJ[am exempt under See. B &P C for thin reason
of conDRAINS FLOOR ROOF,AREA,COND. SANITARY Y N -
Owner Date RECEIPT'M
WORKMAN COMPENSATION DECLARATION TUBES PER TRAP SCHOOLTAX Y N_
C31 hereby afllmn that I have a certiBate sent to self-Inwre,ora RECEIPT p
cdtiflcateofWm1ms'CempetuatEm insueseam.camfled copythereef(Sec' GAS EA.SYST1TTd INC.4OUTLETS PARK IFI Y N
3BW,Lab C.) -
RECEGAS EA.SY51TM-OVFR 4(EA) DING Pia
Co.Cany BUILDING DIVISION FEES
ElCaAfiad copy is heed with the cit. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy b filed with the city Inspection division.
CERTIFICATE OF F.XEMPETON FROM WORKERS' CREASE,TRAP PAID
SATI
COMPENONINSURANCE 200Ff.
(this section need CnetO be SATIdBthePermit la forone hundred dollars SEWER-SANITARY-STORM EA. Date Recei tN
($100)orl..) WATER[iFA'PEt W/VENT/ELECTR ENERGY FEE Y N
I cattily that In the performance of the work forwhlch this permit is issued,
I shall not employ any person In any manner so as to become subject to the WATER SYSTGI/TREATING
Workers'Compensation Laws of California. Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQFr. Date Remi IN
Z 0 NOTICE TO MPLICANC:IL cher making this CertBlnte of Exemption,you
should become subject to the Worken'Comperuation provisions of the Labor TOTAL:
CC N Code,you=at forthwith comply with such Provlslmu orthis permit shall be NGIZ
W j deemed revoked. ''
0�29 7n
f1 CONSTRUCTION LENDINGAGENCY SEISMIC FEE T
I hereby affirm that there Is a construction lending agency for the perform ELECTRIC FEE14 1
Z' ance of the workfor which this permit is heated(Sec.3097,Civ.C.) TTWt
V O Iander'.Name PLUMBING FEE 6`
LL H Lender's Address QTY. "MECHANICAL PERMIT ". FEE MECHANICAL FEE ��
OW Iarti(ythat l have read thisapplicationand statethatthe above lnformoton
Il brormd.I agrnto comply with all dty and county ordinances and state law. PERMIT ISSUANCE l �'s FEES PAID:
>- relating rebuilding mtutroction,and herebyauthortm raper tativesofthln
Zcity to enter upon the above-mentioned property for Wpedisepurposes. ALTER OR ADDTOMECH.
(We)agree to save,Indemnify and keep harmless the City of Cupertino Date R[:eel [b
V against llabWles,judgmen ,manend expenses which may In anywayacome AIR HANDLING UNIT(TO I0,000CFM) SUBTOTAL'
agal Id Ci In nce N
granting of this permit..
I������7I_� AIR HANDLING UNIT(OVER l0,000CFM) CONSTRUCTION TAX
Ignaturcof Applicant/Controdor `' page ' - FXHAUST HOOD(W/DUC'U CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willtheapplia of or future building occupant stemor handle hazardous HEATING UNIT(TO 100,000 BTU)
rwtcrisla.defined by the Cupertirm Municipal Code,Chapter.9.1Z and the Date Recei
Health and Safety Cod ion 25532(a)7 I[EATING UNIT(OVER 100,000 BT(q TOT
Yes i No
ill the a ppllesnt orfutua building occupant use equlperent or devices VENTILATION FAN(SINGLE RESID) - ISSUANCE DATE
which emit hamrdous aU rontaminana as defined by the Bay Area Air
min lily Management De; BOILER-COMP AHP OR 1W,DM BTU) ty A 1 D
4 Yes o H'
have read the hazy °usmalerlas requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health&Safety Code,Sections 25505,25533 and 25534.I
understand that lithe building does not currently have a tenant,that it my NEWREADEMTALMECH. SQ.FT. DEC — 3
rnpons' ilitytondifythe meant fthe requirements which most be met ,
V
prior) uanc rti' to panty.
(/MP3 Ql 6. v®r UUPi
Owner or authorl W agent Date �•
70 ISSUEDBY:.
—
OFFICE COPY