23350 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro ed Identification - - - PERMIT NO.
Building Add rem: - /'�I'3 t'g r 0
. 202// VAlTe7n7 CT. a 0PBf&7*i AA9 CA, .. G�{/l{/rl'�J
nems aces. one: A
/vt/K6 •' j2urr`Y .ya n.ri CITY OF CUPERTINO-BUILDING DIVISION ZFf�Cj Z
` Commeo,'IName: LIc.Na APPLICATION / PERMIT
iS! �ITlY✓NAl/L SV 724 L BUILDINGELECnUCALML BING-MECHANICAL CATEGORY CONTROL
' Ua'ee LI No:
�/uc 2#Te's�++ d'6 7 u G - BUILDING PERMIT INFO
sats To�t QTY � ELECTRIC PERMIT tE
Addreac / cdla,T/�J vPFIWTISSUANCE (� ❑
LICENSED CONTRACTOR'S DECLARATION L.�1
T hereby.fomes that l am licensed under provisions of Chapter 9(commenc. APPLIANCES-RESIDENTIAL K I JOB DESCRIPTION
ingwith Srcdon7000)of Dlvleloo3 ofthe BuslneeeandProfesslonsCade,and my
license Ie In full force and effect. PANELS
LlcenseC ssLIc
'[j .N G L
Date a.�Contnct !a 2
ARCHITECTS DECLARATIO IDI-1000 AM
Kz lundentand my plaueha0 be usedupubllcremNe. OVER NO FT,.FT.FLODR AREA 5/SQ.FT.
00.
Licensed Professional SIGNS ELECTRICAL
6 OWNER-BUILDER DECLARATION
`tn SPFLWLCIRCUIT/MLSC
ZE, Thereby affirm that lam exempt from the C.Mndor'i License Law(m the '
OO following...t5ccUon 7!31.5,Business and Professions Code:Any city or
Fz TEMP.METE[E ORPOLEI
� cwntywhkh requlreaa permit to routmct,alteq Improve,demalbh,.,repair
a any structure prior to Its Issuance,also requires,the applicant for such permit to POWER DEVICES
U Ole a signed statement that he Is licensed pursuant to the provisions,of the
O w Contractors License Law(Chapter 9(commencing with Section 7000)of Divl-
30 S ,","fthe SusinessmdProfeamu Code)orthatheIsezem themfmmand SWIMMING POOL ELECHO VALUATION the asIs for the alleged exemption. Any violation of Section 7031.5 by any '[-(,i/1 l
�GyS appBcantfor.Fermitsubjem the applicant to a civil penalty adnot morethan UILETSSWIICHESFIXTUR d !V 00
E Ove hundred dollars(SM. NEW RESIDENTIAL Frcr SQrT. STORIES TYPE CONSTRUCTION
�n ❑I,as owner of the property,or my employees with wages as their sok
compensation,will do the wor"od the structure Is not intended or offered for
sale(Sec.7094,Business and Profession.Code:The Contractors License Law
s$' does not apply to an owner of property who Wilds or improves thereon,and OCCGROUIP RES.UNITS
who does such work himself or through Ms own employees,provided that such
bnprovemenIs are ns,Intended oro(fered for sale.It however,the building TOTAL:
Improvement issold withinaneyearafcomplmiorytheowner-bu0derwlllhave
ffth rden of proving that he did not build or improve for purpose o(ule.). QTY, PLUMBING PERMIT FLOOD ZONE APN'
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
rontndorn to ronatrud the project(Sm 7091,Business and Professions Code:
The Contractors License law does not apply to an owner of property,who ALTERDRAIN&NEM-WAIIIt(EA)
Wild. or Improves thereon,and who condom fee such p5.jm -
ewith a FEE SUMMARY
cgR(factm(.)licensed pursuant to the Comrades's License Law. BACK FLOWPROTECT.DEVICE
LJ I am exempt under&c. B Is P C for this reason
DRAINS FLOOR ROOF,AREA,CO SANITARY Y_ N_
_. Owner Date RECEIT N
WORKMAN COMPENSATION DECLARATION
jµn that I have a certi(kaonnt
te of cseto self-Insure,or a FDCTURJIS'PER TRAP
SCHOOLTAX Y N
t o re'Comperuallonlruurance ora certifkd mpythereo((Sec. RECEIPT#
3800J.1,0) GAS FA.SYSTEM-1 INC. EIS PARK FEE Y_ N_
Policy# RECEIPT# -
Co�mpany CAS FA'SYSTFM-0 FA
4( ) BUILDING DIVISION FEES
I�Q'CertNed ropy is hereby(umbhed. CREASEANDU L WASTE INTERCEPTOR PLANCHECK FEE
7iLL..�JJCchified copy b filed with the city inspection division. ' (!L,�
CERTIFICATE OF E)(EMPrION FROM WORKERS' GREASE PAID 7:2, S_f�btiQY IagO
COMPENSATION INSURANCE SEINER- NITARY-STORM EA 200FT Date Recel tit
(This section need nat M completed lfthe permit Isfmane hundred dollars �r� '�T
(9100)orlyth W HEATERW/VENT/ELECTR ENERGYFEE. Y_ N_ ,,y_D()
I certify thato the Person in
(.,whichco permit Is booed,
I shall not employ any person la any ser n u to become sub' ro the ATER SYSTEM/TREATINC
Workcrv'Compen ioylavnoltall m .Di ^L1 .� PAID
ZZ Applicant L M_ :e NEW RESIDENTIAL PLMB. SQ.FI'. Date Remi tt!
G NOTICEt APPLICANT:I,after ns, ng this Cectl(ka/e of Dxemptlan,you
should become subed to the Workeri Compensation provisions of the Labor TOTAL: _ 1
N Code,you most forthwith comply with such provisions.,this permit a hall be
WFEE
j deemed revoked. B DING
CL I herebyatOCONSTRUCTION LENDING AGENCY SEISMIC FEE D
rthat there b a routrocilon lending agency forthe perform ELECTRIC FEE
D Z ance of the work(mor which this permit In Issued(Sec.31097,Civ.Q TOTAL: D-
02 Lo.d.e.Name PLUMBING FEE
LL I- L..d.e.Address - QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icedlfythatlhavemadthisapplkatbnandpa thattheabmeNfomatim
C boomed.lagree wcomply with all cilyand county ordinances and pate lawsPERMIT ISSUANCE �t9 FEES PAID:
).' relating to building retrucilon,and hereby authorize representatives of this
NN oocity to enter upon theabovementlonedPropertyfmWpMlonpurposes ALTER OR ADD TOMDCH. . s,0
? (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
V agabut Babilfti dgmenIs, nd expenses which may In anywa a AIR HANDLING UNIT 10,000 CFM) SUBTOTAL: .2a
aIlalnat sal noon n t,.ex n It.
AIRFIANDLINGUNIT(OVERIO,BBBCFM) CONSTRUCTION TAX
Signature of Applicant o actor ,* EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZA DOUS MATERIALS DISCLOS RE -
Wllltheapplicantor(uturebulldingo pam store orhandle hazardous HEATING UMTHO 100,000 BTU) Date ReceI tN
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
Ikalthand Safety Code Section 25532(m)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: t.V
qYen MN.
llllheeppllonl mf wt buildings pantuwequlpment ordevim VENTILATION FAN(SINGLE RISID) I$SIIAIt]Q��ITE
which emithazanimsaircontaminantsascieOned bythe Bay Area Air Q" w u
Q a ity Management District? BOILER-COMP OHP OR 100,000 BTU)
No
�Thivere ,sate ousnuleriabrequlremenIsunderChapter6.95of BOILER-COMP(OVER 100,000 BIL) MAR 13 1992
's r laar.xhhr&Safety Code,Sed1ou 25505,25533and 25539.1
u l�leetand that If the building does,not currently have a tenant,that it b my NEW RESIDENTIAL MECH. SQ.FT. /
responsibility to nd ify the onupaor of the requirements which most be met CI IPI Uh CUr C(II IIsV
prior to issuance of a Certificate of Occupancy.
a
Owner or authorized agent DateISSUED BY:
TOTAL:
OFFICE COPY
,ADDITIONA'L PERMIT FEES
BUILDING PROJECT I DENTIFICATION " VALUAI\H
-* ODPES �6 l i '1'f iA CRTC\. N .
111 EY1 �� IL(%1 1
awnse's '�
NAME
t _ FEE SUMMARY
.y vHarvE - n
' rvT <aen r" ..BUILDING
Ic rbE/ E ~ PLAN CHECK
raNrnActon_s _ ti- FEE: *'
ADDNE55 '
PHONE .'SEISMIC,FEE:,
QTY: ELECTRIC PERMIT FEE
OUTLETS-SWITCHES-RECEP "ELECTRIC 1 .�
LIGHTING FIXTURES �. -
PLUMBING" _ -
" ' APPLIANCES-RESIDENTIAL -
- PANELS'. MECHANICAL -
SIGNS
SIGNSTR(ANS: TOTA +�
SPECIALCIRCUIT
EMP.'METER OR'POLE INS. - ,. -vEvmlr,ynuonnoM _
MOTORS" '}SEE FE SCH: _ *`
O,' r SERVICE CHANGE
CC'y •, y .'IssuRla. DATE t ,
LUOTV.'. 'PLUMBING PERMIT FEE ' aooc rEcr. vac MECH.
ao ; . .
�.Z ALTER-DRAIN'&VENT-WATER(EA.) �.• „� 0
V-0 :BACK'F LOWPROTECT.DEVICE.-
DRAINS-FLOOR,ROOF,AREA COND. 1' '
};y FIXTURES-.PERTRAP'
Z GAS-EA',SYSTEM 1,INC.4OUTLETS� '
GAS-EA.SYSTEM'-OVER4(EA) r
- INDUSTRIAL'WASTE'INTER: / '. At '
V LAWN SPRINKLERS 1 INC 5 V B i 1 1
AWN SPRINKLERS' OVER 5(EA.) r
SEWER SANITARY STORM EA 200ft/;' 1 '
WATER HEATER W/VENT'
' WATER SYSTEM
WATER'TREATING EQUIP:
TOTAL
CITY, MECHANICAL.PERMIT -FEE'
ALTER OR ADD TO MECH,
APPLIANCE`,`
AIR HANDLING UNIT(TO 10000C F M)' p
AIR HANDLING UNIT(OVER 10"C FM.)
' EXHAUST HOOD'IWITHDUCTI QaQQ
HEATING UNIT(TO
i
HEATING UNIT(OVER O100,00BTU.)
VENTILATION FAN fSINGLE( _.cu t, - '
BOILERR 7(3H.P.or100,000B.T.U') VVr {'
BOILER-COMP InM,loopoo erul SEE FEe sce.
LEE
TOTAL