23067 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project identification PFRMITNO.
Building Add ma: 23067
� U� S ���/Dr '
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ners sail: V� p t nne:a CITY OF CUPERTINO-BUILDING DIVISION A A A
cnnmacterr, a `D Lt..N. APPLICATION /PERMIT 1Z' 'meq
• 4 /.SSG r BUfLDINGE,FCTRICAL-PLUMBINC MWHAMCAL CATEGORY CONTROL N
Architaa/Enguat,.. Lk.Na
u< 3.yY [tuck rs * s.-ra.r a, z„u7. 'BUILDING PERMIT.INFO -'
PC= MULTI
QTY �t. ,„ -FELECI'RiCPERMTI' m -'"FEE �,N -
Add. PERMITISSUANCE 1¢ ❑
LICENSED CONTRACrOR'S D LARATION 4P
Ih'by affirm that l am licensed under p laiessol Chapter9(mmmenc- APPLIANCESRESTDENTTAL ]OB DEKZPnON _
ingwe is In Jon7U)ondivfect. heli andlarofeWovCode,wd my /rte 1s�(—�.a.j�]^ Cs•�f
license bin full FrZ and effect. PANELS
Llcen Lh
or ,17
Date Cdradgr UP TO 2DO AMPS
ARCHITECTS DECLARATION 201-IOW AMPS
q00 u pre
I understand my plane shall be used public cords. OVERI(DOAMPS SQ.Fr.FLOOR AREA f/SQ.Ff.
a E Licensed PmfeweLmal SIGNS ELECTRICAL
WNER-BUILDER DECLARATION SPECIALCIRCUTT/MISC
•s„�Z I herebyaffirmtbOm atI am exempt frothe Contreaor's License Lawfarthe
op following reasat.(Section 78715,Business and limitations Code:My city or
TEMP.MEIIR ORPOLE AST.
:o
countywhichrequWs issuance,ms,requirsthe improve,b=tfordemolish,permit
ir
to
j anyNvaure prior tationo lb issuance,theis llsg requires pursuant to the fmsuch ions of tt a POWER DEVICES
file•signed aatsmeLathat he b r 9(coo pursuant it the provisions of the
j6Ou Contrucors License Lw(CNpter9(mmrrcncin with Beaton 7000)o(Divl- VALUATION
05 Non3 of the Business and Pro/eubnsCode)orthatt he is exemptthere(romand SWIM'WNG POOL ELECIWC
J T<f the bub far the alleged exempt Violation a!Section 78115 by any OUTLETSSNTT'CFIFSFTXfURFS -• O 1 v
5”, applicant for a permit subjects the applicant m a civil penalty of net more than U
qq� fi=e undyed dollars NSM. NEW AF500EN17AL ELFLTR SQFr. STORIES =CONSTRUCTION
(a - L j L u owner of the property,or my employees with wages as their sok
ZH^ cempewtion,wWdothe work.andtheahuaurs is not Wended or offered for
C C O sale(Sec 7064,Bustmas and Professions Cade:The Cont adoes License Taw
$ don notapply to an owner of property who builds or improve the.,and OCC.GROUP RES.UNITS
u who doessucb workhlmself orthmugh Nativism employees,provided that such
improvements are not Intended oro8ered for sale.IL however,the building or TOTAL:
Wpravementbwldwithinoneynrofcomplet Ntheowner-Wllderwillhaw .
ti;*.rden of proving that he dim rot build or improve for purpose ofsale.). QTY:. ` t""W'4^'PLUMBING PERMIT;"''?^k,:,>�TEE* FLOOD ZONE APN
Lj L as owner of the Property,am exciwively contracting with licensed ppRMITISSUMrCE .�..e
mntrsdan[o mramed the project(Sec 7014,Business and Professloa Code:
The Contractor's License Law dm not apply to w owner m property who ALTER DRAIN 8:VENT•WATER(PA)
bulls or Improve thereon,and who contracts for such plojeces with a f�-•a-'a^�q,,-(-
�q¢t(udor(N licensed pursuant to the Contraanri License Law. w.:.�._6v.:P::+=,!_.r'FEEjSUMMARY,}"A,r^FC;.;.;
LJ I am exem)rt under Sac 8&P C for this regain Bs«FLOW PROTECT.DEVICETS IDP FEES
Oil Owner Date DRAINS FLOOR ROOF,AREA,GOND. SANITARY RECE N
rte' WORIMAN COMPENSATION DECLARATION SCHOOL TAX Y_ N_
F11 hereby of irm that I have•centfiomss
te o!cnt to ulf-Inwrc,or a F'DCISJRFS PER TRAPRECEIPT N
mrtdicateofWorkeWCompevatim Imuranmora cerviflodmpythereo((S.. GAS EA.SYSTFM-1 AC40UILMS PARKFEE Y_ N_
3800,lAb C.) RECEIPT M
m any S
PaI GAEA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
Com
Certified copy is hereby furnished. CREASE/BJDASIEINTFRCEPTOR- n aP)kCHECK FEE
F1 Certified copy la filed with the city inspection division. _ V Ie 1
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP
COMPENSATION INSURANCE _ Y a. Date Recel t#
O7dseectian need net be completed B the permit later one hundred dollars SEWEILSANITARVr\STORM EA'200Fr' -
(5100)orlessJ WATERHEA W/V�NT[ELEC7R Fr RG FEE Y_ N_
IceMfythac tsthe pedomance of the wok lgrwto beco pemniHeltothe / A
I shall not employ any person in any manner w as to hecnme wbjed to the WATER TREAI7NG —---- PAID--
Wokers'CompenuHonLawsofCaWomb.Date
OZ Applicant NEW RESIDENTIAL PLMB. SQFr. Date Rece1 t#
Z O NOTICETO APPLICANT.If,after makingthla Certificate of Exemption,you
TOTAL:
should become subject to the Worker'Compensation provisions of the Labor
LO Code,you neat forthwith comply with such provisions orthla permit sball be BUILDING FEE
LU _ deemed rooked.
CONSTRUCTION LENDING AGENCY SEISMICCTRL FEE
CL Z Ihfth.w firms tlherelaammtvctinud(Ses, 097,Ci .Cj peaomt ELECTRIC FEE
70TA i�
Z audiee.ework forwWch this pemdtlalswed(See 3097,CIv.CJ _
LL Lenders Addrcu Q7X'>^'?"'.M6CEiANICAI PERMIT•>„;,? '2FfiE`, PLUMBING FEE
LL tion MECHANICAL FEE
0U omiI all to averead
is with p8utlanand dcountyordinances edgat laws
O W barred.building complywnh allcityhereby
auntyice representatives
gate PERMIT ISSUANCE FEES PAID:
8' relatingto
to abvMoryanddproprty otlnreprexnpurpsof this
N city enter apt the above-mill, ned property inspection of Cup s. ALTER OR ADDTD MECH.Z Date Recei t# ;1
(Wd agree t save,Indemnity an d keep harmlen the City of Cupertino
V agaWtliabB es js�nb,coNsan(l ezpenus which may In anywayamve AIR HANDLING[NIT(TO 10,000 CFM) � SUBTOTAL:
against sal C segu, of the granting of this permit.
� ;/9
. �� AIR HANDLING uNTr rovER lB,000cFM) CONSTRUCTION TAX
Signatu o(Appecant/Contractor a EXHAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or hand Is haaardous HEATING UNIT CTO 100,000 BTU) Date Recei t#
material as defirud by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code�+.-S�edion 25532(.)7 HEATING UNIT(OVER 100,00)BTU) TOTAL:
❑ L
Y. _I No
Will the applicant orfuture building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit harurdous air cantamirants as defined by the Bay Area Air P� a5
Qua lily Management D❑istrict? BOMER{OMP OHP OR 100,000 BTU) P A � D
4 Y. H No
have read the Raza o�muterbls requirements under Chapter 6.95 of BOILER-COMP(OVER 100.000 BTU) DEC
•,
the CalifombHealth&Sa! Code,Sections 25505,25533 and 25534.1 1991
understand that if the building don not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQFr
rnpouibdily to notify the occupant of the requirements whkh must be met
prior to issuance of a Certificate of Occupancy. ^IIY Uf VUNCt(I114V
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE COPY