23354 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildinx Protect Identification PERMIT NO. {A�
Building Address: - 2335
1
2211-K-t c.- r= 7—�,'
R Ixonse: APPLICATION SUBMITTAL LATE
I � rv-/v+� 2.5Zrj?,1443� CITY OF CUPERTINO-BUILDINGDIVISION A1 ^'� �Qr-�
Cenlann//rs�Namaa4:�j.L� 'Li..No:-. APPLICATION it PERMIT I�-1 L • -
�—e 1,1`1A"^ BUILDING-ELECTRICALPLUMBING-MECHAMCAL CATEGORY I CONTROL X
ne
Architect/Engier: Lic.Nor
"'• ` ) I' BUILDING PERMIT INFO ,
-- - 1 QTY ," '• .,. ELECTRIC•PERMIT FEE; ' �_�1��
Address / PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(rommena APPLIANCTSRESIDENTIAL J Bit
license li with tofullto.andoffeon3oftFe Busineaand lsrolessiom Code antlm
6 ,
LIcurx Is In full force and kf# PANELS
License Cho LION �'201-1000AMPS
Date CHITECI N'T0l'c ARCHITEe ued as pu RATION OVE1
pppp re0 O I understand my platy shall be used as public records. OVER 1000 AMT'S SQ.Fr.FLOOR AREA 5/SQ.FT.
U0 Licensed Professional I SIGNSELECTRICAL
�Q OWNER-BUILDER DECLARATION
Iherebyaffirmthat l am exempt from the Contractor's License Law for th- SP[CIAL CIRCUIT/MISC
I
7p followingresson.(Section 70315,Buslnessed Professions Code:Any city or
OZI"'qq coon which 1 mitt tomnstmq eter,im rove,demolleh,.rre a TEMP. OR INST. F•
rc, q ty requ resape P p " Y
m 33 nystructum prior to its luuance,ahorequlrcethe applicant(or such perMtto POWER
M file a signed statement the he b licensed pursuant to the provisions of the
Cmdr.cur'sLicense Uw(Chapter 9(rommencling whh.tctlon7000)of Dlvl- C \ VALUATION
COQ slon3ofthe Bueineaand Prcdemom Code).rtM1at hels exempttherefmmand the bas is for the alleged exemption. Any violation of Section 7031.5 by any applicantfora permit subjects the applicant to a civil pemltyen.e more than EC �-'five hundred dollars($500).
NEWRMDENTIALELECIR SQ.PT. _
FIT,..ova r of the property,army employee with wages as their sol^ S Z TYPE CONSTRUCTION.
compensation,will dothe work and the.tructurc is not Intended or offered for `
O sole(Sec.704 Business and Prdeseme,Code:The Contractors LT..L,
does not apply to an owner of property who build,or Improves thereon,and �QC[C.G�R RFS.IIMTS
whod...chworkhimselfor thin.ghhleownemployees,providedthat. - - rI Y (�
improvements are not lntendad or offered for sale.If,hmveveg the building or pl 'O
Improvement issold within oneyea rofcompletion,the owner-bu 0derwdl ha v- A.� I�
tryc.¢arden of proving that he did not build or improve for purpose of sale.). Q7y„•, PLUMBING,PERMIY7 'FEE pLOp NE ApN
L1 L iv owner of the property,am exclusively Business and with lirensc ' PERMIT ISSUANCE I�I
The Contractor's co ns icenseLwdoesSm7pplytsineseand Pro(walonsCode: F ��s
The Coor terprb Liana Law dote not apply m an owner of property why -
buBda or Improves thereon, and who contracts; to such p0o)ects with a ALTER-DRAW&VENT-WATER(EA) '
cgp¢actmW licensed pursuant to the Contractor's License La;,. '� .. ., 101 '•',;'FEE SUMMARY
i LJ BACK FLOW PROTECT.DEVICE gnrcgtr ru�c I
I am exempt under Sec. B &P C for this rcaon I r
Owner De- _- - DRAINS FLOOR,ROOF,AREA COND. I SANITARY Y N I .
_ RECEIPT X
WORKMAN COMPENSATION DECLARATION rIFp(7URgq PER TRAP SCHOOLTAX -Y , N_
❑I hereby affirm that I have a artlBate of consent to self-insure,or a II -I I RECEBT X
M00,mteof Worker%Compensatlonlnsuranreors rerti(Ivd ropythereof(Sec. (GAS EA:SYSTEM-1 INCA � —
�__/ 3X00,Tab C.) I PARK PEE Y N
Pollryp GAS�EA.SYSTEM,OVER4(EA) 1 IN NG DI VI Cam any I I BUILDING DI VISION FEES
OCertlRed copy b hereby fumished.. GRFiISE/INDUSTRL WAKE INTERCEPTOR I PLANCI'IECKFEE
Certified copy Is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION rROM WORKERS' GREASETRAP I PAID
COMPENSATION INSURANCE (SEWER-SANTTARYSIORM EA 200Ff Date RCcei t#
CChb uctlonneed not be complTI Nthe SURAb!.rone hundred doll.. P permit
($100)or Lein.) WATER HEATER W/VENT•/ELECTR I ENERGY FEE Y N
I ex"i(ythe N the perf.munce orthework forwhlch tNe permit is Issued, —
I shall not employ any person in any manner n a to been
Data me subject t PAID
to the WATER gYSTFM/TREATING
w.rkers'c.mpensan.n laws.!Celifornla.
z•Z Applicant
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL ELM B. SQ.IT. I Date Receipt#
should become subject to the Wmkers'Compensat ion provielons of the Labor TOTAL:
N
Code,you=at forthwith comply with such firwWoru or this perMt.hallbet I BUILDING FEE
deemed revoked.
W p' CONSTRUCTION LENDING AGENCY _ SEISMIC FEE _
I hereby affirm t (Sehat there is a construction lending agency for the perform
:3 Z ante of the workfor which this permit is issued&r.3097,Cie.C.) T(leT ELECTRIC FEE
It O Lender's Norm rr PLUMBING PEE
LL F Tender's Address _ - 1QTY.�/ MECHANICAL PERMIT, ' I, . TEE',"I MECHANICAL FEE
O W Irertifyth restoc haveread this
applicationand ordtheaboveinfarmatlon
d. ie rorngto buireeto complywlth andhyabyauthytmropnmand state laws) PERMRISSUANCE I �FEES PAID:
” -
} relating t.building ronstmctlon,and hereby authorize rcpresentalivea ofthis ,
f- 'city to enter upon the above-mentioned property for Inspection purposes. ALTERORADD70MECH.
Z
(We)agree to save,indemely an d keep harmlem the City of Cu pectin. I Date Receipt#
V ageftealiabilltl ,pdgmenb,mste and expen-- hnay In is"way.mmel AIR HANDLING UNIT(TO 10,"CFM) I SUBTOTAL:
against said inconsequence. greeting bpeonit. '
- AIR HANDLING UNIT(0V 70,OW CFM) I I CONSTRUCTION TAX
. ,nature of,ppliarwContrewr to EXHAUST HOOD(W/DUCT) I 1 CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theappliant or future building occupant at..or handle hazard... HEATING UNIT(TO 100,OW BTU)
rmterialasdifined by the Cupertino Municipal Code,Chapter 9.17,and the Date RCCa1Dtf{�,
I lealth and Safety Code r.-S�ect(on 25532(a)7 HEATING UNIT(OVER 1Wp00 BTU)' I I TOI
❑Ye u No a
Will the applicant or future building occupant use e(Iwpment ordevice I VENTILATION FAN(SINGLE RESID) I ISSUANCE DATE
which emit M1arardoua cab mntaMwrd defined by the Bay Area Air
Qu lily Management Distritl7 BOILER-COMP O}II'OR 100,000 BTU) I n p I
❑ Ya No f 1Y
ha re d lhehazardom materials rvqulrrrtsnts underChapler 6.95 of BOILER.COMP(OVIR 100,000 BT U)
the Cs Health kSafety Code,Sectl.ns 75505,25533 and 25534.] _
unit vista red lhatif the building does not come ly have ateranL that itemy NEW RESIDENTIAL ME(]i. S'Q.PEI MAR 1992
' raporuibilltymnaifytheoccopanto(thercqurrcmentswhichmustbemMI
prior to Issuance of a Certificate of Occopanry.
CITY Ur uurcrullav
Owner or authoriud agent Date
' � TOTAL: I (ISSUED BY: _
OFFICE COPY