23984APPLICANT TO FILL IN INFORMATION. WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Budding Address:23984
Io6-3 9 I -A Q ��
PERMIT NO.
site1-Ir6 _.f
IZAIAKVM$3Z V ISWA;PJ e(Hv
�ITYOFCUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
A _AA
�'�. —' Z
Contractor's Nana: tic. Na:
u K E
BUILDINGELECTRICA r'LUMBINGMECI IANICAL
CATEGORY CONTROL 0
Architect/Engineer. Lk. No:
Ngtsf C—
-
QTY ELECTRIC PERMIT. - • FEE
BUILDING, PERMIT INFO
•
Address:
PFRMITISSUANCE
r1V ❑ ❑ ❑
L(�
LICENSED CONTRACTOR'S DECLARATION
-
Herebyaffbm that l sit licensed under provisions of Chapler9(commanc-
li'ngwith SecHOn700D)of Division3ofthe Bushes dPmfemionsCode,and my
cense is In full force and affect.
APPLIANCPSRESIDENTIAL
JOB DESCRQ'ITON
PANELS
Licenre Class Lk. #
Date Commum
LM IQ 2DQ AMPSyD
V�..�.
701-7000 AMPS
ARCHITECPS DECLARATION
I understand my plans shad be used as public records.
OVERIODOAMPS
SQ. FT. FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
SPECIAL CIRCIRT/MLSC
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt fromthe Contractor. Lkense Law for the
TEMP METERORPOLEINST.
following reason.(Sectlon7MI5, Busruois.d Profesions Code:Anycityor
cwntywhkh mquimsa perrdt tommtmd, altey Impmve, demolish, orrcpair
anystructure priorto its issuance,alsorequires theapplicant forsuch permitto
file a signed statement that he is licensed pursuant to the provisions of the
POWER DEVICES
SWIMMING POOL ELECTRIC
OU7LE.IS54VI.ICHFSFlXilJRFS
Contractor's License law(Chapter 9(commencing with Section 7000) of TEA.
sion3ofthe Bushrosand ProfesionaCode) orthat he is exempt therefromand
the Lasa for the alleged exemption. Any violation of Section 70315 by any
applicant for. permit subject the applicant too civil penalty of not more than
VAL ADO,
7� Q
NEW RESIDENTIAL ELECTR SQ.FT.
five hundred
as ownerdollars of pr. employees with wage as their sole
❑ of the property,
STORIES
TYPECONSTRUCTION
aowner
u
compensation, will do it he e is ot intendedContractor or d for
Business oil Pmedthestm i
Business and Professions Code: The Contractors License law
The Law
sale (not
does not apply loanowner ofproperty who hereon
apply to
nemplrImproves
who does such work himsUorthnngh his own employees, provided that such
ovidedreatsuch
OCGGROUI'
RES. UNITS
improvements are not Intended proffered for sale. If, however, the building or
TOTAL:
Improvement issuld within one yearofcompition, the owner-bu aderwill have
mturden of proving that he did not build or Improve for purpose of sale.).
se
U L as owner of the property, am exclusively contracting with licensed
contractors to construct the project(Sec. 7W4, Bushes and Profendom Code:
QTY. PLUMBING PERMIT FEE
FLOOD ZONE
APN
PERMIT ISSUANCE
The Contractors License Law does not apply to an owner of property who
bunds or Improves thereon, and who contracts for such p(uject with a
pursuant to the Contractors Licenslaw.
U I or exempt under Sec B & P C for this reason
off,
ALTER -DRAIN &VENT- WATER (FA) `
BA FLAW PROTECT: DEYICE,� I�s
FEE SUMMARY
D SFR OR ROOF, AREA, CONDI
SANITARY Y N
RECEIPT #
Owner Date
WORIKMAN COMPENSATION DECLARATION
F-11 hereby affirm that 1 have a certificate of consent to se141nsare, or a
certificate of Workers'Comperwtion Insurance ora certified copythereot(Sec.�
380, Lab C.)
Policy p
(FIXTURES PER TRAT'
SCIfOOL TAX Y_ N_
RECEIPT M
'.
PARK FEE' Y N
RECEIPT
GAS FA. SYSTEM -OVER 4 (EA)
Com any
BUILDING DI VISION Fr. ES
[Certified copy Is hereby furnished'
❑CertUed copy a filed with the city Inspection division.
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHL-CK PEE
ae
GREASETRAP
CERTIFICATE OF EXEMITIONFROM WORKERS'
PAID
��O' rb�
COMPENSATION INSURANCE
(this section need no[ be completed ((the permit a(or one hundred dollars
SEWER -SANITARY -STORM EA. ](LOFT.
Date RCCCI f#
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y N_
($300)or less')
I cortify that U the performance of the work forwhich this permit Is issued
WATER SYSTEM/TREATING
1 shad not employ any person in any manner so as to become subject to the
Workers Compensation Lavvofoufomla. Date
'PAID
NEW RESIDENTIAL PLMB. SQFT.
Applicant
Date Recei t#
NOTICETO APPLICANT: If, after making thisCertificate of Exemption, you
shwidbecome subjetmthe Warken'Compenaatlon prowmna pone Labor
TOTAL:
B ILDING
-OU
Code, you most forthwith comply with such provisions or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
S"U
I herebyaffirmthat there is a construction kndingagency forthe perform-
ance of the work for which this permit a issued (See. 3097, Clv. CJ
Lender's Name
Lender's Address
I certilythat I have madthiupplicatimn and statethatthe above Information
iscomcd. agree to complywith all city and county ordinances and state laws
TOTAL:
-LECTRICFEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
.
FEESPAID:
relating to building construction, and hereby authorize representatives of this
city to enter upon the above-mentioned property for inspection purposes.
(We) agree to save, IndemNfy an d keep harmless the City of Cupertino
against liabilities, 7a it ,costs and expenses which may lnanywayacaue
against said consequ ce of�the granting of this permit.
�� / %IIb �`�
ALTERORADDTOMECH.
nBle Recei f#
P
AIR HANDLING UNIT (TO IO,OW CFM)
SUBTOTAL:
AIR HANDWNG I1Nl"f (OVER 10,000CR1)
CONSTRUCTION TAX
T
Signature p II ujG -r,-
HAIEARDOUS MATERIALS DISCLOSURE
EXHAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
-
HFATING UMT(TO 100,000 BTU)
-
Date Recei f#
Will the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.17, and the
Health and Safety Code Section 75532(1)1
❑ Yes ri No
Will the applicant or future building occupant use equipment or devices
which emit tuerdous air cents mina nus as defined by the Bay Area Air
Quality Management DisMttP
4 Yes �� o
have read the
ialth& materials requirements 15533 and 255r8.95 of
Code, Sections1!15505,have that I'
theernad that if the a tenant,
understand that❑the building does not currently have atenanq that itis; my
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
F A I V
y q(�(�
JUL 1 1 'IDJ2
BOILER{OMP DEEP OR 100,000 BTU)
BOILER-COMP(OVER 100,000 M)
NEW RESIDENTIAL METH. 'lQ.Ff.
noerfadCertificate of Ococfvtphaenresyq.uirementswhkh must be met
prior to issuance-
CITY Ur
�lavrCnluvV
ISSUED BY:
Owner or authorized agent Date
TOTAL:
OFFICE COPY