23606 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification - PERMIT NO.
Building Address: 2 3 6 0 6
I G �- to 14�--rou p rt-1
weer. am. (� `
6 b ey -L L mv-2- S I_ CITY OF CUPERTINO-BUILDING DIVISION d
Contractor's Name: t LIc,No: APPLICATION'/PERMIT Let- Z
BUILDING-ELECTWCAL-PLUMBING-MECHANICAL CATEGORY CO
Architect/Engineer. Lic.him I t!407
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE E] ❑
LICF.NS ED CONTE ACTOR'S DECLARATION
I hereby affirm that l am Bernard under provislooa of Chapter 9(mrrv.nc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwlth Sectm,7000)af Dletdon3 ofthe Busleassand ProfesslonsCode,and my
Bernet,Is In full force and died. PANELS
LicenseChss Lent -
Date Conlnctor IOO AMT'S
ARCHITECTS DECLAMTION 201.1000AMI5
p�p�uu reO Zp I understand my plaro shall be used as public remads. JOVERIODDAMPS SQ.FT.ROORAREA ^ $/SQ.FT.
E t) Licensed Prdeadonal SIGNS ELECTRICAL s,['1 I, 43 {/� L-:6(a
<< w OWNER-BUILDER DECLARATION SPECIALCIRCUIT/M15C J vC••r VV a
OR- owingyafRrmSectiom31.5,Bexempt(romtheulI'mfctore,Code:License nycityoraw for the Zaq [�
faltowingmescan,ichmq lracta n7071.5, melnessand Professlaos Code:Anycityir (vim
� cauntywhich rcqulresa pertNt tomnd.R,alter,lmprove,demoWh,orrepair TEMP.MEf[R OR PoLE]NST.
q� a anyetrodure prior to its barance,atsorequlmtheeppllant farevch permitto
LS�w fie a signed deterrent that he ti teemed pursuant to the provlslo es of the POWER DEVICES
Owl Contractor's License Law(Chapter 9(mmmencing with Section 7001)of Divl- VALUATION C54301H�OS slon3ofthe Budnessand ProfesslomCade)orthathelaexmptthemfmmand SWIMMING]POOL ELECTRIC
ll �n the basis for the alleged exemption. Any violation of Section 70715 by any
applicant fora permit subjects the applicant to a civil penalty of not carve than o OUTLETS-SWITCHES-FIXTURES ` R( D I✓� — '
five undredd Ioft5500). NEW RESIDENTIAL ELECTR SQI-T. STORIES TYPECONS)RUMON
�n an
s owner o(the property,or my employees with wages as(heir we
c pe mtlon,will dothe work and the structure ls not intended or offered for
D ea (Sec.7044,Business and Professions Code:The Contractors License law —
�$ does not a pply to an owner of property who builds or Improves thereon,and R IIP R'
who doessuch work hlmsolfor through his own employees,provided that such
Improvements arc not intended or offered fee sale.If,however,the building or T
Improvementlsmld withtnoneyearo(completion,theowner-bullderwlli have -
th urden of proving that he did not build or Improve for purpose of sale.). QTy. PLUMBING PERMIT Mr, G"613
LJ I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE NE/
contractors to construct the poled(Sec.7W4,Business and Penitent..Code:
The Contractors License Mew dm not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) TE
builds or Improves thereon,and who comment for such p -
Rajeda with a FEE SUMMARY
do Bmnxd pursuant to the Contractor's Leenx Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sac. B k P C for this recon
Owner DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
Date REC�.M
WORKMAN I haveaNSATION DECItand to
FD(TURF_S.PER TRAP SCHOOL TAX Y_ N_
❑I hereby aflonsiron that I have o mMOrne of consent to opytheurc,(Sa RECEPf N
380),critiab ofWorkeri Comps.atlonlnsurance ora certified mpythemo((Sec. GAS EA.SYSTEM-1 INC.4 OUTLETS PARKFEE Y_ N
3ROQ Lab C.)
I'oliry Y RECEI'I'X
CEMGAS EA.SYSTFhLOVER 4(CA)
Y BUILDING DIVISION FEES
urtCcdiRedmpyls herebyfurnished.the city
GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑CeKltled mpyls(ied with the city Inspection division. 9 3L(oC
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARYSTORM EA 2001rr Date Recei a.-�
Rx
Flselion need net be completed R the Permit V .(orohundred dollars
(f100)orlemd WATER HEATER W/VENT/E.FCTR ENERGYFEE Y N
]certifynt that In any personhe in any
he crar oak n as to
eonhis permit b Issued, l
7 shag not employ any person f any runner m u to become subject to the WATEi SYSI7M/TREATING O
Workers Compenution levee or GllfornB.Date PAID L
C) Z Applicant
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.FC. Date Recei t#
Fshould bemmesubject to the Workers'Compensatian provlsio.ofthe Labor TOTAL:
N Code,you most forthwith comply with such provisions orthis permit shall be
deemed revoked. B
W
C CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that them is construction endingagenry for the perform-
n Z aom.fthcw.,kf.rwhIchthi,permit is Issued Issued(Sec.3097,Civ.C.) ELECTRIC FEE
Q O Lenders Nemo PLUMBING FEE
IL H lender's Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W
VIcedltythatl luvc read lhlsappllollonand da fo
lethal theabove Inrmation
1 Iecorred.l agree to comply with all eltyand county ordinances,and date laws PERMIT ISSUANCE FEES PAID:
>. M relati.gtob.lidt.g..tmdion,.nd Mrebyauthori mpresentativnofth6
Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
— (We)agree to save,indemnify an d keep hamNess the City of Cupertino Date Receipt#
.gala llabllltiee,Judgments,mdeand ex cases which mayln.nyway.cum. AIR HANDLING UNIT(TO 10,0DO CFM) SUBTOTAL'
agalnslu In con arm of the g permit AIR HANDLING UNIT(OVER I D,ODOCrW CONSTRUCTION TAX
SI of plant enure le EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISC L E
Will theappilcant or future b.11chegoccupant store rh ndlch,'.rdous HEATING UNIT(TO 100,000 BTU)
material as defined by lM Cupertino Municipal Code, er9.IZ..dtha Date Recel t
Iieahhand Safety Cade Section 25532(a)I HEATING UNIT(OVER 100,000 BTU) TO A
❑Yee No
Will the appllcantw Lure bdilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) - ISSUANCE DATE
which emit havardous air mnlamlm rata as cleared by the Bay Area Ab
Quality Management District? B0ILER-COMP(3HPOR 100,000 BTU) B$ p B
4Ys ❑No
have read the hazeNeas materials requirement under Chapter 6.95 of BOILER.COMP(OVER 100,000 BTU) r
the California Health k Safety Code,Sections 25505,25533 and 25534.I
understand that if the building does not currently haves tenant,that It le my NEW RESIDENTIAL MF.CH. SQ.FT. � og 9QTy�
rapo.lblllty to notify the occupant of the requirements which must be met
Prior to issuance of a Certificate ofOccupanry. CI'/Y
Owner or authorlard agent wt. lir �Uh' TYf tVl
TOTAL: ISSUED BY:
OFFICE COPY