24232 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NQZ 4 2 3 2
Building Addmss:
1'313
s a� _hone.
r t-'\wmzv� (�,?:7 -'f (.` CITY OF CUPERTINO-BUILDING DIVISION
Cent attcr uaNe:' APPLICATION / PERMIT
•� �)' .I BL9LDINGfl,ECTRICALPLUMBINGMECHAMCAL CATEGORY C
Architect/ ginsr. Llc.Na:
Q}'Y tr;iaa x ( ELECTRIC A`kim�'Yt:,. 711.1'FEH, '°."'BUILDING PERMIT,INFO 4 �' 'r
Address PERWTISSUANCE 1 `
LICENSED CONTRACTOR'S DECLARATION L�
S hereby
rction70that lam Bce3ofthe usine provisions Chapter ssions9dc,and c MPllANCESRE57DEnTIAl OB DESCRETION
It...h in
to00)of d effeon3otthe BuslnessandP fessions(:odc,and my -
licenu b in tub to and effect. .� � (- l( -Z— PANES
License Clay Lie.M
Date - • - Contractor I-
( '� ANCHITECPS DECLARATION 101-I000AMPS
O Z I understand my plans shall be used as public records OVER 1 ODO AMPS SQ.Er.FLOOR AREAayy $/SQ.FT.
f�
X00 Licensed Protea Tonal SIGNS ELECTRICAL r 237,
<<W OWNER-BUILDER DECLARATION lTI aV v
n> SIPFLIAL CIRCUIT/MLSC
FZ� Theeby of fro.thso ,Limnu Law fort he
LfelOwing reo .(Section70
31.5,Rusinessand Professions
Code:Any city or
TEMP h{ELER ORIOLE INST.
muntywhirh requites permit to construes,alter,Improve,demeltsh,errepair
.Put anystm=mpAorto(tatssuancgaWmquimstheappUmntforsuchpermitto POWER DEVICES
file a signed statement that he b licensed Pursuant to the provisions of the
�� Contractors Liceruelaw(Chapter9(mmmencingwith Section 7000)of Divi. VALUATION
G SWLMMING POOL 7 EC 7UC
., 0 5 the basis fo th i alleged Profeaion. Any violation
f exempt lhercfromany �� �
-Sn the basis for the alleged exemption. Any violation of Section 7Qf15 by any
�✓« OUiLE7S5WiTCFiESFIXNRFS
applicant for a pemdt subjects the appilcan!to a dull penalty o(nd more than W
? five hundreddollarshe X1).
❑I as of property, NEW RESIDENTIAL ELECTR SQFr. STORIES TYPE CONSTRUCTION
, p perty,or he employes with wage as thele sole
compensation,wBldothe work and ions;C durc V not intended or offered for
sale(Sec 7064,Business and Professions Cade:The Contrador'e License Law
$ does not apply to an owner of property who builds orimprevsthereon,and
S^ whodoessuchworkhfmselforthraughMsownemployes,provided thatsuch OCC.GROUT' RES.UMTS
Improvements are not intended oroffered for sale.If,however,the building or T
improvement nssold within oneyearo!completion,the Owner-bu0derwillhave
- - a
the When of pmvingthat he did not build orimpmve for purpose ofsal ) QTy,y �'ej ,PLUMBINC,PERMIT ,m *N: FEE'ti FTAODTDNE APN
❑1 u owner of the property,am exclusively contracting with licensed PERMTT ISSUANCE
contractors to construct the project(Sm 70K Business and Professions Code:
'Die Contractoes License Law does nes apply to an owner of property who ALTER-DRAIN&VENT-WATER(FA) _
W Bds or Improves thereon, and who contracts (w such p(ojects with a 1 -...eFEE$UMMARY. rI
connrictor(s)BcensM Pursuant to the Contractor's License Law. 1 if.-�y'y T.D --
•
[:]I am exempt under Sec B k P C for this reason - _ OUTSIDEFEES
Owner Date
NS FT.DDR' OODj SANITARY RECE3 T 0
WOAIU1fAN COMPEg5AT10N DECLARATION !' SCHOOL TAX Y_ N_
F-11 hereby affirm that I have a certificate of consent to ulf-insureor a
N
PARK FEE Y certfBcateofWorkem''Compenaallonlrouranmora certBiedespythertro!(Sec. RECFRRa
3800 Lab C aQ G wxY5 1 LNC UTL _
Po)icya_ -6,V dQ2Z6673C0 ts- GASEA.nsrM
RECEIPT i
BUILDING UI VISI QNFEES (
�CifiCTd copy is hereby (shed. GREASE/INDUSTAL WASTE INTERCEPTOR PLANCHECK FEE �C
❑CeKertified ropyssfiled with the city inspection division. ''11
CERTIFMATE OF EXEMPTION FROM WORKERS' GREASE TRAP _ PAID �{rx
COMPENSATION INSURANCE
(17bissimionneei not becomplded ifthe permit Lsterane hundred dollars SEINER-SANITARY-STORM EA.200FT. R i t
(SIDBorless.) ENR FE YV_ipt#
_
Icertifythat inthe perfomunceofthework forwhich this permit is issued, WATER HEATER W/VENT/171 TR
LUZO
I shall not employ any person In any manner sou to become wbjed to the WATER SYSTEM/TREATING P D
Workers'Compensation Laws of California. Date
Z Applicant N'EW RESIDE!,TIAL PL.MB. SQFT'. Date
= O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should become sub}xt to the Workers'Compensation provislons of the Labor TO Al-
in Code,you mut forthwith comply with such provisions erthu permit shall be BUIL LNG FEE
m
11 > deemed revoked.
cONSTRUMON LENDING AGwcY SEISMIC FEE
L [hereby afflrrothat there es a construction lendingagency for the d m ELECTRIC FEE
7 Z ance ofthe workfyryofc thLa tuume (Sc.qM)7,CIvaC)
O Lender,Narre_(,�(1� L 9 .y - y.., 1 .. PLUM
BING FEE
F t<naeranaarca -S,n Sac✓•3-s /ae �/fa_in.�t QrY: MT a;�IECHANIaoERMIT ». ;F£E
[p MECHANICALFEE
L U leertlfythatlfuvereadthisapplicatio...ditatethattheabovemformation
W iscorrect.I agmeto comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
Q. relating to building construction,and herebyauthorizerepresentauvesofthis
Zcity to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH. Date RCCeI
Me)agrcc to save,indemnify an d keep harmless the City of Cupertino
against babNties,judgments,measand expenses which may in anyway accrue AIRHANDLING UNTT(I'O10,0)0CFM) SUBTO
againsty brconsequirtbeof the granting of this permit. CONSTRUCTIONTAX
AIR HANDLING UNIT(OVEOD
L IO, OCFMI
Signatureof Appbcant/Contractor 15atx, IXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant orfuture building occupant store or handle hazardous HEATING UNIT(TO IWWO BTU) Date Recei t
material..defined by then pertino Municipal Coda Chapter 9.11,and the
Healthand Safety Codon 2S532(a)? HEATING UNIT(OVER 100,000 BTU) TOTA
❑ Ys No
Will theapplicam or future building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hazardous air contaminantsasdefned bythe Bay Area Air . . ".,
Quality Maragcment c ? BOILERCOMPOHP OR IOO,MD BTU)
❑Ycs No
} Ibaveread the ha matemi requirements under Chapter 6.95 of BOEER-COMP(OVER 100,000 BTU)
-� the California Ilealth h Safety Code,Sections 25505, `— `'-7
533 and 2SSM. I S r-
undersund that ifthe build ing does not m rrentlyhavea tenanLtha,itis my NTIV RESIDENTIAL MECH. SQ.PT. LjEC 16 9992
responsibility to notify the occupant of the requirements which most be m2
prior(oiavanee of a Certificansof Occupancy, ,
Owner or authonmd agent' Hate, ISSUED BY:
t
OFFICE COPY