23997 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ea ldmtiffceil �Ia PFR.MH NO.
Building Add.: 13U 23997
rcr• areal: Phom, DAlh
' js-3Z'g 5 CITY OF CUPERTINO-BUILDING DIVISION 07- 2-"
� �",,,,L
• cm a me: Lic.N''o. APPLICATION / PERMIT (
Architect gl jr LCT9�N 3 BUT DING EaECIRICAL-PLUMBING LAICAL CATEGORY
Qrr ELECTRIC PERNjrVFEE BUILDING PERMIT INFO
Address OVO C�13P_.L�nI �i�' � '�' PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm the l am licensed under pmvbims&Chapte,0 foremen APPLIANCES ]OB DESCR➢'110N
Ingwlth Sectic.70(0MI)NI.I Mihe Busl.and PmfeaME.Code,eid /�' ` �L
licerm bin full d effect I`_i PANELS
- Ort n�C ARCHI'fEeCTS DECLARATION r,2E:V1- A. // �O�I • `v��`—"'
reOZ ]underMard my phro shaghe used upubkcremnda OV 1 SR.FT.FLOOR AREA f/9,�.FT.
Q OWNER-BUILDER DECLARATION ��i I PPI II V
p a Iherebyaf ornthatlenexampl fremthe Contractori LlceueLAwforthe SI'EQAL UfT/
qqqq following reason.(Sealm 70315,Buenm and Pmfeabu Code.,Any city or \ /
ZOZI"' conn whkh Iron and mrutru alter,lm TIIdP.MEIl7t ORPO 'Sf. 1 I\ `�
F� ty pq pe ut pmvadamolbh,o to _ 1. ..�
q any atmaeR prbmentthe nal I,Enemed beth t to the provi outs of t e POWER DEVICES `-e��/��
file a signed statement that he b Timecard punwnt m the proWabro of the
fG71;w Contractori LiceroelawiChipter9(mmnnndngwkh Sec1bn70W)d Dwi- IL'
&OS O SWIMMING Ia00L ELECTRIC sbn3ofthelus nand PmfmWmCode)orthehebexempttherefromard �f VALUATIO G
< ib HLAs for the alleged exemption. Any violation of Section 7MIS by any l ` J�
applicant fora permit abjeea the applicant to a civil penalty dm mom than OUTI.EISSWITCF@S17XT[JRFS J .J) O u ^—
g$ By£-Iundred dolhn 05M. NEW RmDQJTTA
O.. I,a owner of the property,or my employees with wages u their Mole �� STOW6 TYPE CONSTRUCTION
compemrtlon,wW dothe wort,and thestruma,is not intended or offered for
C p aI-(See 70M BualneM.M Profmalo.Code:The Contractors Uoeve law
$ doe notapply to an ower of property who builds or lmpmvee thereon,and OCC.GROUP RFS.UNITS
whodoessuchwork Nruelf orthrough wownemployeea provided thatach
Imprm.m actratintendedorofferedforuk.ILhowever,thebulMingor TOTAL:
Improvementb"wkhinomyearofcanplebn,theownerWBderw UHve
t"rdenofprovingthat he did not buddorimprm.eforpurpoMofale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE AM
LJ L u owner of the property,am exclusively contracting with IkevM ' PERMIT ISSUANCE
to construct the project(Sec.700 Buetres and Tiofesebm Code:
The Contractor's License Law does no apply to an owner d property who
Wild.or Improves Merton,and who coram for mch p(ojects with a ALTER-DRAIN&VENT-WATER ff.0
91111-dor(s)lomaed pursuant to the Contncta'M Lloeme law. BACK FLOW PROTECT DEVICE FEE SUMMARY
UI am exempt under Sec. B&P C for this morn
Owner Dale DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION R) EU'fa
❑I hemby affbm the I have a certificate of consent to self-inaure,or a FIXTURES.PER TRAP SCHOOLTA% Y N_
RLCEIPI e
mrtl(Icate of WorkedCornpensatlmlnsurancemaartilkd copythemof(Sec. GAS W.SYSTEM-1 INC4 OUTLETS PARK FEE Y N
3800,1 b C.) RfCF]
Co11cy I GAS E.A.SYSTEM-OVER 4(EA)
Cray BUILDING DIVISI NFF.ES
Cent Merl copy b hereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE 05
WCertified copy b filed with the city inspection dlvwm.
(7ERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCEgpWpUyg,ANTp,Q(Y SIOAM EA 700P1' RCOeI t#
(Thissectionneed not ecompleted lithe permit bfmomhundred clones
WATER HEATER W/VENT/ELFZM ENE G Y N
I cert0yth the b the perf.mwce of thou work f.rwNch thispemUt b famed,
I.ME)na empby any mmi ywnner m u to hw b tgthe WATI➢(srsTTaf/n2FnnNc PAID
Wwkcnv'Com�eryatlp mos oi�pCa_q*nla.Date 'l 4
O Appnu _`1/VLii T171()d s Date i t#
Z 0 NOTICE TO A#FLICANT:It,a ma king lw Certlficer.f Exemption.you NEWRESIDENTLV.PLMB. SOFT.
F N should become subject to the Workers'CompeuMtbn provWoro&the Labor T AL:
Code,you nue forthwith comply withsuch pmv oamthio permit shel be aas��
c — deemed rekrd. BUIL12ING FEEW
WCONSTRUCTION LENDING AGENCY SEISMIC FEE
a Therebyafflim that then b a comtmctim lending agency for the performELECTRIC FEE
Z ante&the work for which this permit b famed Gee 30x7,CIv.C.) TOTAL.
(� O tender.Name PLUMBINGVE
'.. LL F Lcndcr.Addrea QTY. MECHANICAL PERMIT IEE MECHA
O W I certify thatl have mad thbapplicatbnand sntethaltheabeve informatlm
1 bmrmt.Iagmeto comply with all city and county ordkuco
ns and elate laws PERMIT ISSUANCE FEES D:
>. 03 bPurpura, ALTER
to building corutruction,and hereby authorlu repraienteh<s oftw
(_ city to enter upon the above��ntbned property for up—ion PurpuALTER OR ADDTO MECIL
? (We)agree to ave,Indemnify an d keep harmless the City of CupertinoReceipt#
agaW,HbWtin,judgmevm,m.aand expensea whld may N anywayamue AIR HANDLING UNIT OO I0,OD0 CFM) SUBTOTAL:
agaluce t ofd City in cortmquenof the gmming&this permit.
H
AIRANDLINC DNTr rovFR Io,DDocEM) CONSTRU ON TAX
Signature.!Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRU ON TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfutum buildingoccupant Mort or handk ha'ardous HEATING UNIT(TO 100,000 B'Rl)
metrial.adefld ro by the CupertiMunicipal Code,Chapter 9.17,and the Date R t#
re
IkethandSafey Cod Se im]SS37W7 HEATING UNIT(OVER 1WO,l1W BTU) TO
F1 Y. No
WOltheappBcad futurebuildingoceupantuaryuipme,M ordrvices VENTILATION FAN(SINGLE RI9D) ISSUAN DATE
which rout ha EaMMS air caniaMvMs as defined by the Bay Area Air
Quality Maagcrmnt 7 BOILER-COMP DEEP OR 100,00q BTU)
4Ym No
u ne.dtheh du . ties requirements under Chapter 6.9S of BORER-COMP(OVER100,000BTU)
the Oluomla Health&Safety Code,Sectlom 25SCS,riS33 and 75534. I
underMand that if the Wilding don not currently have a tenant,that it b my NEW RESIDENTIAL.MECH. SQFT PAID A ' D
respomibilky to notify the occupant d the req.1mmenis which moult he met %
or to lsnua d Cc care ofOmtpanry.
,e.4_ a1 � EP I .
net or thorizd.geni tD�e TOTAL ISUEDBY_ �(
• ••n 1vVrCfTI11VV
OFFICE COPY