23373 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification PERMIT NO.
Building Addme° 23373
ere arse: one: A
ptv &/- CITY OF CUPERTINO-BUILDING DIVISION
aC dor.N.me: Lie.No: APPLICATION / PERMIT
C '^ BUILDINGELECTRICALPLUMBINC.MECHAMCAL CATEGORY CONTROL N
Architect/Engineer. Lk.Na
BUILDING PERMIT.INFO,t7•�,:
`,
&Y S, ELECTRIC PERMITr°
Add. PER)ATISSUANCE El
LICENSED CONTRACTORS DECLARATION
I MrSbction7O=ofamllcrosedunder R.31 w mPmfesMpter9(ormmmc APPLIANCESRESIDENTUL JOB DESCRIPTION
Incense is ecilon force and died.3o(tht BudrcasandPreldslonaCode,andm
license le In fuLL fors and died. PANELS
Llmnse Clase Lie.0
Data Contractor ,9 I �
ARCHITTCPS DECLARATION 701-1008 PS
otz I understand my plana shall be used as public ccmds OVFRIOOOAMPS SQ.FT.FLOOR AREA $/SQ.FI.
HLI Licensed ProfmWnal SIGNS ELECTRICAL la �' D I N
6
OWNER-BUILDER DECLARATION SPFCIALCBtCIRT/hf1SC - - -
I_ � Ihereby affirmthat l am exempt from lM Contractor's License Law for the gin.-.�.
^� ^ following mason.&S .70!15,Buskmasd Professions Code:My city or TEMP.MEIFRORPOLEINSf. / �y T ` R
G7j muntywhichrequbesaper towratruckalter,lmpmve,demolbh,ormpalr `' �
Sanyshuaumpr toitsbeuance,abomryimtheappBantfo wchpermltto POWER DEVICES
ufile a signed statement that he b Bcorsed pursuant to the provbiom of the 6 2_
Cmarame.License Law(Chapter9(mmnentlng with Section 700M of Divi- SWIMMING POOL ELECTRIC ---------------=ATIO
e•�OJ s n3ofthe BuWmmd Prdmiom CMe)ortbd Mbewmptthem/mmand
q 6.....77777 the Geis fee the alleged...minion. Any violation of Section 70315 by any O[TiLE.ISSWIT.C}{ESF7JOlJRpS
it
LS' o app0onn fora permsubjects Neapplicanl toe civil penalty d not me.then
flue T,as owner
nerofdollarthe property,
NEW RESIDENTIAL ELECTR_SQ.FT. STORIES TYPE CONSMUCTTON'
s..!n tope asoon,wOl oche prtmdthe employee with endedwages utMbsola
kZ< d for
ate(Smad44.Busdossa wmk,andthes Cdumbrot Wended oronse Law
�F D sale bee 701q Business and Professions Cody.The ContntloYs License Law
e] $ doe not apply to an owner of property who baikls or improves tMmon.and OCC.GROUP RES.UNITS
a. who doessuchwork himself orthrough hbownemployees,provided that such
Improvements arc not Intended or offered for We.If,however,the building or TOTAL
Improvementis oldwithinomyearofcompldWmtheownenbuilderwillhave
tfAkurdeno/proving that Mdid rwt build or bnpsove(or purpose o(vak.). QTY. PLUMBING PERMIT- 'FEE FLOOD ZONE APN
U L as owner of the property,am exclusively mntradleg with licensed PERMIT DANCE
contnttorn to construct the project(See.70K Busi=esand Pro(mlons Code:
Tia Contractor'.License Law dm not apply to an owner of property who
bunds er Irove to therm and who co=ma for such with a ALTER-DRAIN&VENT-WATER O'A) _
elf,
ebu(tl licensed pursuant m the Conbaders License Law. BACK FLOW PROTECT.DEVICE :-a . '• FEE'SUMMARY�*:
LJ I ec am exempt under SB&P C for this mason
Owner Data DRAINS FLOOR,ROOF.AREA.COND. SANITARY N RFCE _
� WOR KHAN COMPENSATION DECLARATION FIXTURES.PER TAM SCHOOL TAX Y_ N_
rIl hereby affirm that I have•cartlMta d consent to self-bwm,w a RECEIPT N
cartBlcateo(Workeri Compensation Insurance a ordBied copy thereof Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
38170.Lb C.) WCy7Oon2_I RECE1[8
Potlry N GAS EA.SYSFFM.OVER 4(EA)
Com any BUILDING DIVISION FEES
Certlfled copy b here by to ""d
CREASE/WDUSIRL WASTE WCER.CQsTC)R PLANCHECK FEE
Certified copy b Rigid wllh tM eily iropeccbn division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID
COMPENSATION INSURANCE SEWER.SANITARY-SPORM FA 200FT Date Reoei t#
(Chis section need net be completed Ethe permit Isfor one hundred delta=
(SIOO)orlm.) WATER HEATER W/VENT/ELECIR ENERGYFEE Y_ N_
I terrify that in the performance of the work for which this permit is issued, 77
Er
I shall not employ any Pa.N any manner m as to become subject to the WATER SYSIFM/'TREATTNG
WorMri Compensation Laws of Ca Wmb
o .Data PAID
O Z Applicant NEW RESIDENTIAL PLMIL SQ.FT. Date Receipt
Z O NOTICETO APPLICANT:U,after maHngthb CertBlcateof mExxonp1We,you
N should become subject to the Workers'Compersallon provbm
ioolthe Labor TOTAL:
CC ; Code,you=at forthwith comply with such provisions orthb permit shall be BUILDING FEE
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 I hereby alnrmthat them b a mmhutHon lendkg agemy Ter tM perform T ELECTRIC FEE
� Z anceoftlown kfor which this permit b Issued(Sec.3097,Civ.C.)
02 L<ndef.Name - r•. - - PLUMBING FEE
H Lendc,.Addmne QTY. '•;L. -MECHANICAL PERMFf�•?%;e2 '.;':FEE
LL U I cadllylhatl have nadthbappecationa d statethattheabovelnformation - MECHANICAL FEE
'O W bcomd.I agree to complywilh all cltyand countyondiances and nate laws PERMIT ISSUANCE FEES PAID:
} 0. relating to building cumtmction,and hereby authorize mpresematives of this
F Z city to enter upon the about,mentioned property lm Inspection purposes. ALTERORADDTOMECH. Dale Recei t#
(We)agree to save,Indemnify an d keep harmless the City of Cu pertiro
I..I agaimalbbWties,}'Ldgmems,rodaande.pataes whK may In any=ayamme AIR HANDLING UNIT(TO 10,0010 CFM) SUBTOTAL:
agai ai i nl �.nna u.r�a rN nunguH a nit AIR HANDLING UNIT(OVER IO.ODO CF.O CONSTRUCTION TAX
L.
i Signammo AppOcant/Con ratter Dau EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfulum building occupant store or handle hazardous HEATING UNIT CID 100,000 BTU) Date Recef t#
material as defined by 1M Cu penin Municipal Cade,Chapter 9.17•and the
I ealth and Safety Code Section 75532(a)I HEATING UNIT(OVER 100,000 BTU) TOT
r-1Ye No VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
Willthe
tum building occupant use equipment ordevice
hichemitnagement aircontamimnbedellned by the Bay Area Air
• slaty Management Dbtrict7 BOILER-COMP OHPDR 100,000 BTU) A 0
Yes ❑No y
have mdthe huarlTOus materials rrequirement,under Chapkr6.95 o1 BOILER-COMP(OVER 100,000 BTU)
M
the Giifomia Health&Safety Code,Sections 25505,25533 and 75531, T .ya,RESIDENTIAL MEIN. SQFf MAR 5
understand that it the building does nd cumently have a tenant,that it b my 199L
resporuablllly, d to notify the occupant the requirements which must be,mot fS�
prior to issuance of.Certificate of Occvpsmy.
0�Y I I i' 1-s "Nu
TOTAL:
Owner or aulhorived agent Date ISSUEDBY' A
OFFICE COPY