23993 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
B"Ro"' Address 4 : 5 1 23993
_2
one: A A A
CITY OF CUPERTINO-BUILDING DIVISION
contra .nanism' �Q� Sf S3� TLk.No: APPLICATION / PERMIT
Architect/Elnce
BUILDING-ELECTRICALPLtJMBING-MECHAMCAL CATEGORY CONTROL#
ngr. n�IF YSTL�N t �I� QTY ELECTRIC PERMIT' FEE BUILDING PERMIT INFO
Address//Je2 C r PERMITISSUANCE I� ❑
LICENSED CONTRACTOR'S DECLARATION
IMhSb ion7OW)affirmtha.lamlicensed l,i.3ofthdHrprovis.d Ps Chapter9(commrnc- APPL[ANCESRESIDENML JOBDESCRB'QON a 1
IngwlthSeelon7000)of Dlvialon3o(the Businemand Profemlom Code,and my 2 WY'TI/ .
lice..is in' roe and effect. � O �S[y PANELS Gp"
Llan lam k.# 3 sir tr�I l a
Date Contractor
ARCHITECTS DECLARATION M14000AMPS
�Z I understand my plans sMR be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
❑O
xZ(3 Licensed Profemlonal SIGNS ELECTRICAL - LED N
6 eon OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC T E R
L., i4 I
owing y affirm moson. that I amction7 I.5,Buempt romthed Professions
License Law lotto'
Op Z F following red req(&sloe permit
to Business and Pro prove,Code:Any city it �P.METER OR OLE INST. n
3, onsinanystywhire requires p'mute,alsorualreatheaprovederrouor ch permit
to
any atmcNre priorto statement
that
he J,licensed
pursuant t 0th' rovislhpermit a !OWER DEhCES KV V
lJ Ole a alga's statement that ha V licensed pursuant it the tion 7000) of the TE
ail Conrado/s License LawrtF .er C( de)erthth.bemmptthem)ofDivi.and SVITAMING POOL ELECTRIC -
i- thesiobasis fa the alkge dPrcfembm Code)octad n of exempt therefrom and VALUATION
Q
applicant
lusb for the permit
su exemption. Any vlolatbn of Section 7031.5 6y any __.
« app hundred apemstaubjcctstheapplkanttoa civil pemltyMoat morcthan OI177'E'1SSW[TCFfESf7X7'URFS�
c. five hundreddollars he pr). NEW RESIDENTAL ELECTR
Jp, � asownerll otproperty,or my employees with wages offered
esok SQ'FT' STORIES TYPE CONSTRUCTION
compensation,70 Buss ess andhe work,and thee Code:e isTh Co nerd's or License
for
so le(Sec.7064,Business and Profemloru Code:The Contraeol's Llarue Taw
S� does not apply to an owner of property who builds or improves thereon,and
0. whodoessuchworkhim.lforthrough huriam employees,provided thatroch OCC.GROUP RES.UhT15
improvements are not Intended oroffemd forsale.If,however,thebuilding or TOTAL:
Improvement bsoldwithin oneyearofcompidlo,the owner-buOderwlll have
th Nen of proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOG WNNE APN
Lj 4 as owner of the Property,am exclusively contracting with licensedPERMIT ISSUANCE
contractor to ruination the project(Sec.7064,Business and Professions Code: `.�
IS
Thr,ContZolore Llan.Taw does not apply to an owner of property who
W IQs or Improve'thereon,and who contracts for such pW"with a ALTER-DRAW kVENT.WATER(FA)
ryIllfaelons)bcensed pursuant to the Comracor's License Law. RACY FLOW PROTECT.DEVICE FEE SUMMARY
L_j I am exempt under Sec. B lk P C for this mason
OUTSIDE FFLS
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N
• WORKMAN COMPENSATION DECLARATION RECEIPT=
❑I hereby affirm that I have a certificate of consent to self-Insure,or a FIXTURES.PER Y PTRAP SCHOOL TAX N
aNBcete of Workers'Compecouni n Insurance ora¢rtifled copythromf(Sec. RECEIPT#
3500,Lab C.) GAS G.SYSTEM4 INCA OUTLETS PARK FM Y N
Policy# RECEIPT p
Com any GAS G.SYSTEM-OVER4(FAT BUILDING DIVISION FEES
[Certified copy is hercbyth the city
GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copyvnl'd with the tlrywpeelon awlamn.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRGSETRAP PAID
COMPENSATION INSURANCE
(Thlssedionneedootbecompleted Otbepermit lsformishundreddollars SEWER-SANITARY-STORM EA.200FF. Date Reeei l#
(5100)orlemJ
I WATER HEATER W/VENT/ELEGTR ENERGYFEE Y N
certify that ti the per(omunco of work for which this permit Is l'ou'd,
1 shall not employ any person N any manner so as to become subject to the
Workers'Compem.tbn Laws of Calfomia.Date W^T�sYSTr2.4/rRGTTNc
O PAID
Z Appllemt
Z O NOUCETOAPPLICANT:ILaftermakingthuC .t off teof Exemptbn,you NEW RESIDENTIAL PLMB. SQpr. Date ReOai t#
should beerme sub)ect to the Worker'Compensation prov000ns of the Labor TOTAL:
Cr N Code,you resat fort hwlth comply with such provisions or this permit shall he
W > damed revoked. MTR
/�
Ix p CONSTRUCTION LENDING AGENCY
I hembyafBrmthat there is amnstrudlon lendingagency forthe perform- TO
7 Z ance ofthe work for which this permit b Issred(Sec.3097,CIv.C3
U O Lender's Nam Iy <naeranaaremQTY. MECHNCAL PERMIT
O W I certify that l have readthisappBatamsend state thattheabove Information
V ounce.l agree to comply with all d and county onlinancesand state laws PERMIT ISSUANCE ��'
FEES PAID:
} 1 relating to building romtruelon,and hereby autFarlu reprcsentativea of this
N
city to enter upon the ahova-mentioned property for Inspection purpmes. ALTER OR ADD TO MECH.
? "libil
e,Indemnity an d kap harmlem the City of Cupertino Date Receipt#
gmenrs,co and ex sea which may InanyweyacerueAIR HANDLING UMT(TO 10,000 CFM) SUBTOTAL:
onseq se of anting of this permit.IX „ AIRHANDLINGUNrT(OVERIO,000CFM) CONSTRUCTION TAX
nt/Contractor �e �Y Date — EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willth'appilca nt or future building ottvpan,store or hand le havallous HEATING UNIT(TO I W,ODO BTU)
roiterla I as defined by the Cupertino Municipal Code,Chapter 9.12,and the _ Date RL'Cei t#
lieahh and Safety Cod'Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU)
F-1YeaM No TOTAL:
Will the a pplicant or future build ing occupant use equipment or devices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which coMv
lt rdous air mntaMvnb as defined by the Bay Area Air
Qua fity Ma wgement Dist Her? BOMER-COMP DlDP OR IWD(*BTU)
haw'mad the baza ua m -f�alerlals requlmments under CM pter 6.95 of BOILER-COMP(OVER 100,000 BTU) IT a
the C iifmla Flealth k Safety Cod,Sedbns 2x505,25533 and 25534. I
understand that lithe building does not comantly have a tenant,that it is my NEWRESIDENTTALMECH. cS .FT 0 1992
roporuibility to notify the occupant of the mquimments which must be met 'JUL
prior to Issuance a a Certificate of Occupancy.pan
.
n J
Owner or authodred agent Date sH
ISSUED BY:
OFFICE COPY