23784 'APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY
Building Pro'ect Identification PERMIT NO.
Building Address:
D10?_7 Am v/F-T-PifA-It- 23784
wnereA
Nl�p t�N/ r—J �r ✓+� 73�i (°frLDAM
CITY OF CUPERTINO-BUILDING DIVISION /
Contraux's Name: - ua No: APPLICATION / PERMIT- . P ' a"
^w '� IV&-J31 DI BUILDING-ELECTRICAIIILUMBING-MECHANICAL CATEGORY CONTROL#
ArcMtnd/Engineer. Lie.No:
?gTr ;� ECEG'FRIC PERINI'T ' t'.AEE ,: " BU...... 9 PERMIT INFO
Add ss:
PERMIT ISSUANCE ❑' ❑ ❑
LICENSED CONTRACTOR'S DEC"
RATION - -
Ihereby affirrnthatlamlicensed under provisions ofChapmr9(mmmena APPLIANCES-RESIDENTIAL' JOB DLSCKI'IION
Inensci Seciion7f100)of Dlvfect. ofthe Bueinessand Profeaelons Code,and my
licence la In(ul force and d(ect. PANES •
License Chas Lic.#
Date Contractor UP TO 2DO AMPS
ARCHITECTS DECLARATION MI-1000 AMPS
roOQ I understand my plane shall be used as public records. OVER 1000 AMPS �. RAREA- $/SQ.Fr.
. Z(�j Licensed Professional SIGNSELECTRICAL -
6 OWNER-BUILDER DECLARATION
7 & Ihereby affirm that l am exempt from the Contradorb License Law forthe SPECIALCIBCUIT/MISC p p�
pp followingreason.lS Hon7031.5,Bualnessand Pmfe.s .sCode:Anydtyor , i' /•V ii. It•••
O Z t.µ9 t' TEMP.METER ORPOLE INST. '
�� countywMch requlreea issuantealso reud,estheapmve,demoWh,ormit to -•
.-: any atmdurepdortoitshat he
lice regWrersuant t the
risions of the
! L7Lz,
I�Rle a signed statement that he h Ilceneed pursuant it thetle.70 ) ( the IX]WER DEVICESVp..('antradors,knesLew roxesser9(com)or(hatwith xedion7000)ofDivi- 1.�
slon3oftheBusiness end ProteulovaCode)orthat he lsexempttherefromand SWBr1MING[IDOL ELECTRIC CATIONthe basis for the alleged exemption. Any violation ofSection 7031.5 by any {1L
applicant for a permit subjedstheapplicantto a civil penalty,of not roorethan OOILEISSWITCHFS.FI%T11RF5
05� five hundred dollars(S500),
I,as owner of the property, NEW RESIDENTIAL ELECTRSQ,FT.
�n p perry,or my employee with wages as their sohSTORIES TYPE CONSTRUCTION
compensation,will do the work and the strecture Is not intended or offered for
O sale(Sec.7044,Business and Professions Code;The Contractors License Law
p1 F does not apply to an owner of property who builds or improves thereon,and OCC.GROUT' RLS UNITS
CC,, who doessuchwork himselforthreugh hlsownemployees,provided that such ,
lmproveeentsarenaintendedorofferedfasale.15hmw egthebuildingor TOTAL,
improvement bsold within oneyeam(completion,theowner-buMerwill have
to ben o(proving that he did net build or Improve for purpose of sale) QTY, ','�PtiUMBING PERMIT t' ;•FEE."'.... FLOOD ZDNE APN
as owner of the property,am exclusively contracting with licensed PERMI,,,k,ANTE -0y
rontractore to construct the project(Sec.7044,Business and Professions Code: /
The Contractor's Limns,law does not apply to an owner of property who ALTER-DRAIN k VENT-WATER(FA)
builds or improves thereon,and who contracts for such p(ojects with'a .. " 'f'EE$UMMARY+'
cgR1(ador(s)licensed pursuant to the Contractors License Law. "
1.11 am exempt under Sea B k P C for this reason BACKFLOW PROTECT.DEVICE
Owner - DRAINorl
S FLOOR ROOF,AREA,COND. SANITARY Y_ N
. Date RECEIPT#
WORKMAN COMPENSATION DECLARATION pp(TURLS PER TRA[' J SC[i00L TAX Y N
❑I hereby affirm that I have a ceni0cate of consent to self-Insure,or a RECEIPT#
cedifkateofWorkers'Compermatimlosunnceoramnifiedmpythereof(Sec. GAS EA.SYSTEM-11NC.40[I'ILECS . PARK FEE Y N
3800,lab C.)
Policy# RECEIPT It
Com any GAS EA.SYSTEM-OVER4(EA) BUILDING DIVISION FEES
Certified mpy is herebyth the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified mpy h(fled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
- COMPENSATION INSURANCE SEWER SANITARY STORM EA.100FT. .Date Rech t#
Qhie aecilon need eat be completed BCM permit h(atone hundred dollars
($1�I0)orlesc.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Ill net thatlnthep Fork [.sof thework for tobecmermlHcito the ,l
I shall not employ any person In any manner m e to become subject to the WATER SYSTEM/TREATING
Workere'Compensation Iowa of Gll(omla.Date PAID
Q Z Applicant
Z O NOTICETOAPPLICANT:lf,aRermakingthb CertBicate of Exemption,you NEW RESIDENTIAL PLMR.__SQ,Fr, Date Recei t#
should become subject to the Workers'Compensation provisions of the Labor -~ TOTAL:'W Code,you must forthwith comply with such provisions or this permit shall be -
LU j deemed revoked. '' BUILDING FEE
CL C CONSTRUCTION LENDING AGENCY -Z /'- SEISMIC FEE
Iherebyafflrenthat there is a construction lending agency forthe perform �d4 ELECTRIC PEE
D O ance afthe work for which this permit is lsseed(Sec.3097,CIv.C.) TOTAL:
'(> _ Lender.Name PLUMBING FEE
LL H Lendcra Addreaa QTY. :' MECHANICAL"PER •'.'FEE-''
O O I camlythatl havereadthisapplicationand statethatthe above Information MECHANICAL FEE
aboomed.Iagreetocomplywithalcityandcountyordinancesandstate)aws PERMIT ISSUANCE
N relating to building construction,and hereby authselze representatives of this 8
(— Z city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH. -
_ (We)agree to save,indemnify an d keep harmless the City of Cu period Date Receipt#
against liabilities,judgment,mats and expenses which may In any way acme AfRHANDLING UNIT GO I0,W0CEM) ' SUBTOTAL:
.galnstskd Cit Inconsequence f the granting a this permit.
—9z ' AIR HANDLING UNIT(OVER IO,fIDOCFM) CONSTRUCTION TAX
.Slgnatuy of Applies anted Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
/ HAZARDOUS TERIALS DISCLOSURE
Will the applicantor future bull Ing occ'upantstore or handle hazardous HEATING UNIT(TO IDg000 BTU) Date Recei tri
materlalasdef(ned by the Cupertino Municipal Code,Chapter 9.17,and the - -
Heaith and SafetyCode Section 25537(.)7 HEATING UNIT(OVER IOO,OW BTU) ' TOTAL:
ill the appilcznt or future building occupant useequipmentordevices VENTILATION FAN(SINGLE RESID) I$$U�iN�CEDbTE
�which emit hazardous It contaminants as defined by the Bay Area Air IWP'i
. Quality Management District? _ BOILER-COMP DHP OR 100,000 BTU)
4Yes n No
havereadthehau�ousmaterhlsoequirtmenbunderChapterG95of 9O LER-COMP(OVER 100,000STU) J�N (] 1992
the CalifornW Health h Safety Code,Sections 75505,25533 and 25534.1
understand that lithe bulldingdoes not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.pT.
responsibility to not lfy the occupant of the requirements which must be met " /
prior to Issuance a a Certificate of Occupancy. - CI It ur. Lu'ct111I11 U
Owner or authorized agent. +Date ISSUED BY: � �� •w'ti����
TOTAL:
OFFICE COPY