23378 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: _13 23378
w a Came: one: APPLICA11UNhUBM111ALUAlh
CITY OF CUPERTINO-BUILDING DIVISION �' L
Lic." APPLICATION /PERMIT
'� J 1 /o:S BUILDINGELECTRICALPLUMBING-MFLHA MCAL CATEGORY CONTAOLM
Architect/Englneer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE. [j [:] ❑
LICENSED CONTRACTOR'S DECLARATION
I hercby ectionaffirrintlaft 7000)olam Ocensedunder proviaod Pro Cslons ods,anenc APPLIANCES-RESIDENTIAL J08 DESCRB'TION
Ingwe iii i.to I7000)of d effecn3oftheBwinessandPro(esUonsCode,and my /
license la In full rce and effect, j� LIPT02 /
PANELS
Llmnse Cbn Lic# ' /`n/rA//` •✓%f
Date S+iL/-O ) Cent raeor , �� bL•esi( {v
_'-nstan ARCHITEcus DECLARATIO OVER 10AMI'S
02 (understand my pians slug be usedmpub8crecorls. OVER 1800 AMPS SQ.FT.FLOOR AR $/$Q.FT.
t O
a U 5 Licensed Professional SIGNS ELECTRICAL
<<Y1
G F OWNER-BUILDER DECLARATION
SPECIAL CIRCUIT/MLSC
H 7 Ihercbyasorm5ectio exempt 731.5,B(romthe Contractor's License Law fort he
ALE 0 IN
Z O..' following recon.(Section 70015,Bualness and Professions Code:Any city or FR
O 7.F�. TEMP.METLROR POLE(NSI.
� county which rcquircsapermitmrons[sect,al[er,lmprove,dertnlish,or repair
P Q� anystructure prior wits hsaance,aLso requlrestheapplicant for such permit to POWER DEVICES
V file a signed statement that he b licensed pursuant to the provisions of theqe
3Lj
`"In awapterContractor's License Law(Chapter with Section 7003)of Divi- .
SWIMMING POOL ELECTRIC
F•�O� the basis fo BuaNewand Professions Any violation is exempt therefrom and N
the bash for the alleged exemption. Any ttol.civil
of Seaton 7m1.5ne any
j
OUTLE7SSWITC1iFSFIXTURES t
five
hundred doermitsubjectathe applicant too tivil peoaltydna more than
w• R fivehundreddollarsheSOB). NEW RESIDENTIAL ELECTR SQ.FI. STORIES TYPECONSTRL'CTION
Z¢ ❑e as owner of the property,or he employees with wages as their sole
compensation,Business
and
Pr andthes Code;Th na intended or olercd for
5 O sale(Sec. pply toainowandf property
Code;The or Impn,wes Licctheme law
does not apply torn owner ofaprough who Wilds own employees,
that
OCCGROUP RES.UNITS
who domsuch am nm nt a ped or offered
Msowne.If,ho lie pr,the building
u ldi such
improvementsarenaintended earofcdforsale.If,4hower-b deer ill have TOTAL:
Improvement bsold proving thin one id not Codd or i n the efor p r,cae ofsahave
try,wrden owerf the p he opeid nawedorvely c o metingpwath licensed
QTY. PLUMBING PERMIT FEE
LJ.4aa owner of the property,am exclusively contracting with Iirensed FT-OODID:VE APN
contnaors to construct the project(Sec.7064,Boniness and Profeaskus Code: PERMIT ISSUANCE �r'
The Contmaor's License Law does not apply to an owner a property who ALTER-DRAIN k VENT-WAIER(EA)
builds or Improves the , and who contracts for such pRojects with a - FEE SUMMARY
tnctor(s)licensed punuanttothe Contractor's License Law. BACK FLOW PROTECT.DEVICE
I am exempt under Sec. B k P C for this reason
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
_ OUTSIDE FEES
Owner ECLDesRECEIPT F
WORKMANIhay .COMPENSATION DECLARATION FIX.NRFZ PER TRAP SCHOOLTAX Y N
❑I hereby affirm that I have a certi0ote of consent bself-insure,ora RECEIPT#
certificate of Worken'Compemation Insurance or a certified copy thereof(Sec.
L..� GAS EA.SYS[EM-1 INC.40U7LEI5 PARK FEE Y N_
3000,Lab C.) RECEIPT#
Pdiry# /�1 J3 3 3p O — `/.� cAs En.sysrEhfoveR a EEA)
Com anv STs/: Y/a�fJ�
BUILDING DIVISION FEES
LCertifi�py la,RFmby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
W -
ortNed copy Is filed with the city Inspection division.
Yl CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWERSANITARYSTORM EA 200ir1' Date Recei t#
(This section need not be completed if permit is for one hundred dollars
($100)orless.) WATER HEATER W/VENT/ELECTR S ENERGYFEE Y—
N
I unifythat N the performance of the work for which this permit is issued,
I shall not employ any person N any manner so as to become subject to the WATER SYSTEM/TREATING
Workers C°mpensaOon Lawsof Czlitomb.Date PAID
C' Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
Z O NOTICE TO APPLICANT:14after making this Certificate of Exemption,you
should become subject to the Workers Compensation provisions of the Labor TOTAL:
N
Code,you=at forthwith comply with such provisions orthin permit shall be BUILDING FEE
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d Ihereby afflrenthat there L9 a construction lendingagency forthepeamrm- ELECTRIC FEE
TOTAL: ��qq qq ��-
0 ancewof ork(car which permit issued(Sec.3097,CIv.CJ v
V Lender'ser', uName PLUMBING FEE
LL H Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW ImrtifythatlluvemadthBappliotionand statethattheaboveinforeration
1 Iscoreea.Iagree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. relating to building construction,and hereby authorlu representatives of this
H N city to enter upon the abovecrantioned property for Inspection purposes. ALTER OR ADD'O MECH.
Z (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
V against liabilities,pdgerents,costsand expenses which may in anywayacaue AIR HANDLING UNIT(TO 10,000 CFM) - SUBTOTAL:
against said City in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CF) CONSTRUCTION TAX
Signature of Applicant/Contranor Date EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture buildingomnPant store oihamleh..rdous HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the —
Health and Safety Code,$catlon 7S532(a)7 BEATING UNIT(OVER 100,000 BTU) TOTA
❑.Yes •j(t�C1 No �a
Will theapplicant rluure building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
whichemitharzrdousairmntaMmntsasdetincdbythegay Area Air .
Quality Management a. M57 BOILER-COMP OHPDRI(XbIXU BTU) MAY 14 1992
I Y� a��°
have mad teeth meds,Le reons 2555,2553 and 2S5r6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health h SafetyCode,Sections currently
h,25533 and 25534. I
respntandthatntify the the
poet of to rmntlymnts which
that biamy NEW RESIDENTIAL MI(CH. SQ.Irf. /x Lts)ox.J /-�
re�sppomibneymnaify the oavpant ache requirements wMch must be ma vlrY Ur `U)' 4 1
poi r biw..nceof.CCertifii toff 97 Fancy. V0
ser oauthorised-agent Date )ggUEp BY:
'IOTA L:
OFFICE COPY