23542 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildingProject Identification - PERMITNO.
Bulyrg Addre,,: - . . 2354L.
wnery one:
WITIOW tV (,, CITY OF CUPERTINO-BUILDING DIVISION
� c°rbat°:,Name: le2•N°' APPLICATION.I PERMIT
J BUILDING-MECTRICAI-PLUMBING- CATEGORY CONTROLp
MECITAMCAL
Arch)es/En er. Llc,No:
a 'QTY. t �, ELECTRIC PERMIT! ' 't''�FECt Ice`., .BUILDING PERMIT INFO
n
Address: 23 _ wt We�iar[O a6 PERMRTISSUANCE �Q�
LICIINSEOCONTRACTOR'SDECLARATION X K t—�
Ihereby affirm that l am Licensed under provisions of Chapter9(mmmenc. APPIIANCESRESIDENTIAL JOB DESCRIPTION
ingwith SeMon7000)of Divislon3ofthe BuMi sand Professions Code,and
e Is lull( and died. PANELS ✓
Limn an Lic.p 77719
_W141
1i
odor r �r1'L
ARC shall
used
as p ARA TION OVER0000AM 1
q0Z lundentand my plans shall be uvnd as public OVER1000 ANTI'S SQ.FT.H.oDR AREA •4/SQ.Fp.
q��uu O .
hi Licensed Professloml SIGNSELECRICAL -
<< 41 OWNER-BUILDER DECLARATION kt
to, G IherehyafBrmthatlem exempt from the ContContractor'sLicense Law for the SPEIALCBRCUIT/MISC -
FZ 7 foeowingreasee.(Ses1on7031.5,Buslnessand Professions Code:Any dtyor TEMP METER ORPOLE INST. -
t' county which requlresa permit tommtruct,alter,improve,demolbh,orrepalr
°��t .a aoystrudure priorm its(ssuance,also requireslhe applicant forsuch peuNtto
W V file a signed statement that M b licensed pursuant to the provisions of the POWER DEVICES'
3w Contntor's Lice Lw(Chapter 9(commensn with Section 7000)of Divi- -
O fn B SWBr(MNG POOL ELECTRIC
sion3of the Business and ProfessionsCode)orth,t he b exempt therefrom and VALUATION
65 the basis for the alleged exemption. Any violation civi ofnat1on 7031.5 by any OUTLETS-SWITCHES �/ ♦9
applicant for.permit subjects the applicant to a scull penalty
of not more than a/ I/
c. O live hundred dollars(A500. N - SIO)iR'S TYPE CONSIR[K710N J
I as owner o!theproperty,or m employees with wa e,a,their sole NEW RESIDENTIAL ELFG7R
�n ❑• e],avB �' '
compensation,Buwilinessdo a work and the ions Code:The
not Intended or offercense Law
In(Sec.apply
toanow owner
ofpropProfeserty
Code: Contractors License Law '
a $$ docs not apply town owner ofproperty who Wilds orImproves thercon,and
whodoe.such work himself orthrough his own employees,provided that such - c' O RES
�. .. Improvements are not Intended orolfered for sale U ltowevegthebulldingor TOTAL. `7 _ 1.
Improvement bsold within mayearofeempltion,themmerbud erwlll have
the burden of proving that M did not build or Improve for purpose of sale.). QTy. `t�• LUMBING,PERMIT}
L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE 0
contractors to construct the project(Sec.7044,Business and ProfessionsCode: -
The Contractor's License Taw does not apply to an owner of pmpety who ATE/j6
ALTER-DRAIN&VENT-WATER(PA)
Wilds or Improves thereon, and who contracts for such prujedo with a VIS
�t(ador(,)limnsed pursuant to�M1e Contractor's Llnnx Law. ;ti{-.t
-IJ I am exempt under Sec. B &P C for this reason BACK FLOW PROTECT.DEVICE
r t.
Owner - - Data DRAINS.FLOOR ROOF,AREA SANITARY Y N
GOND. RECEIPT# .
WORKMAN COMPENSATION DECLARATION / FLYIIIREi PER TRA(' '(J SCHOOLTAX Y N
I}JI hereby affirm that I have a certl0ote of consent to vel(-inwreor a RECEB'f Y
I to ofWmkere Compensation Insurance ora ceMfled copythereof elar. GAS EA.SYSTEM-1 INCA
3800,Lab C. /A, PARK FIT? ,RECI]Irfp
Polity,a GIS d 7J 07�7—bL GAS EA.SYSTI]Tl-DYER 4(FA) ..
Com env .49 ♦ 1' BUILDING DIVISION FEES
�CcrtiBed copy b hercbytumecity GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�ertifledropybpled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
' COMPENSATION INSURANCE' ' SLWER-SAMTARY-STORM G.XIO}Tf. Date RCCCI t#
(This sedton need not be complied Lithe permit is forms hundred dollen
(4100)otifyth WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Iron( thato the person in any
crosser
se ast become
permitis booed,
I shall not employ any person Ir any manner m as to become subject to the (NATER SYSTEM/TREATING
W Applicant
laws of California.Date PAID -
0 Z Applicant NEW RESIDENTIAL PLMB. SOF('. Date Recel t#
Z O should NOTICETOA,subject to
after rs'Comakinprorationhis proviscate ofions
Exemption,you
Code,you
subject the Workers'such provisions,
ruason pmthia pomxt s Laborbe - TOTAL:
LU W Co meds r muet forthwith comply with such proal tons or[hb pemJl shall be Q
> scanted revoked. FEE'
W — CONSTRUCTION LENDING AGE1,1CY SEISMIC FEE
'a (hereby a(lirm that there ieamrmwslon lending ELECTRIC FEE
agenryfortheperform-
� Z ' ance°ftheworkf°rwhkhthbpermiti.Lss d(Sec.W97,Civ.C.) TOTAL:
L) O ]enders Name - PLUMBING FEE - Z . 00
F Lender'.Addrcn - QTY. '. MECHANICAL PERMIT �' I� FEE,•
O O 1oertilythat I have mad thbappllation and statethatthe above information - MECHANICAL FEE
W
bcomert.I agree to complywlth all city and county ordinances and state law, PERMIT ISSUANCE, .OV FEES PAID:
>. relating to building constrvdlon,en by authorise reprexotativesofthis - -,
Z city to enter upon the above,me red
piopedy for Wpe<too purpose.. ALTER OR ADDTO MECH.
(We)agree to save,Inde ity d keep harmless the City of Cu Penton Date Receipt#
.V agalnet Illtin;ju and expenxs which may Iran wayacerue AIR HANDLING(IMT 8010,(100 CFM) SUBTOTAL: 3
agai Id City Inc ,n e of the granting°(thio pe
AIR HANDLING UNIT(OVER 10,000 CIM) CONSTRUCTION TAX'
CONSTRUCTION TAX PAID:
re o(A i /Contras Date IXFiAlJS'TIIOOD M'/DUCT) , �l�(, -
AZARDOU MATERIALSDISCLOSURE `
Willthea cart or future building occupant store or handle havrdous HEATING UNIT(TO 100,000 BTU) - Date Reeei t#
materials. fined by the Cupertino Municipal Coda Cha)xer 9.17,and the -
Ilealthan fety C°de Sedion2S53Z(a)7 HEATING UNIT 100,000 BTU) - TOTAL:, x3o
❑Yes MN. . - -
Wllltheapplicantorfuture building occupant useequlpmenl or devices VENTILATION PAN(SINGLE RESID) - ISSUANCE DATE
whicheMtharardousalrrontamimmsa.defined by the Bay Arm Air
Qualitm1 -
yManageentDistrid? BOILER-COMP pHP DR I00,IXq BTU( •W A-0
n❑Y:a N.
.. (have read the hazardous material,requirements under Chapter 6.95 of BOILER-COMP(OVFR 100,010 BTU) ' fl�1 /n�r�{ �Q(]�
the California Health&Safety Code,Section,25505,25533 and 25534.1 .. APR.^Y Io 2
understand that if the building does not currently have a tenant,that it is my NEWRFSIDENTIAL hfECII. - SQJFY.
spoof bility to not ify the occupant of the requirements which must be met
prior to issuance of a Certificate of Dau pa racy.,
CIIYtUr,C`urcnw{w,J ,
O..mmzulhohmd agent DateISSUEU BY:
''TOTAL:'if
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