23514 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
BuildingER
Pro'ed Identification PERMIT NO.
Building Address:
io saw �y _ T� o 23514
cancra one:
CITY OF CUPERTINO-BUILDING DIVISION L,f
c°"t�aa .Nae: N : APPLICATION / PERMIT ( l C
ArchBILDINFICTRCAUMBINMCCATEGORY
Lic.No: � CONTROL
?4019
G
N TY QELECTRIC PFE
ERMIT E BUILDING PERMIT INFO
5 • PERMI775SUANCE �q
Adorns .ay ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby on7OODffirm )olam Rcm3oftheunder
usimprovisions o(mionsr9(mmmmc APPI]ANCFSRESIDENTIA JOB DFSCRI'TION
Ing a. SeMen7000ol Divlstm3o(the Bualnerandlsro(erlonsC-ade,and my
Licnr ialns (a cad .0 PANES `Ha�
Date Class Lie S__
Date Contractor 401
ARCHITECTS DECLARATION /
OZ I understand my plana shall be used as public OVER IM SQ. FLOOR AREA S/SQ.FT.
LED IN
o(Oj Licensed Professional SIGNS EL C
6
OWNERI am-BUILDER DECLARATION SPECIALCIRC / r,�
zF, owing yaifiran m.(Samm7exemptfrotheossa d Professions
License Law fort he 9P, ..
�`p Q following reeson.(Seaton 7m15,Business and Pro(essiom Cade:Any sty or
E'� muntywhlRirequlmapermktomnatrua,after,Improve,demalIsh,orrcpalr TEMP.METER O Ib [NST. �j
e�`'15,�a�Q anystructure pdorto its asuance,al,orequlrestheappllcant forsuch permit to POWER DEWCES V �7
C w V ilk a signed statement that he Is licensed pursuant to the provisions of the
0 Contradoes Licerue Law(Chepwr9(mmmanang with Seaton 7000)of Divi- SWIMMING POOL ELECTRIC VALUA77
SOS elon3o(the Businessand Professlor Cmde)orthat he Isexem)rt themfromand
<� the basis for the alleged exemption. Any violation of Section 70115 by any OUTLETS-SWITCHES-FIXTITRES
applicant for a permit subjectathe appllcanuo a dull penalty deed more than V
five hundred dollars($500.
I,as owner of the property, NEW RESfOENTlAL ELECTR SQ.Ff. STOW TYPE CONSTRUCTION
�n ❑ p perty,or my employer with wage as their dole
compensation, the work and the structure The
not Intended or coffered for
C rLe(Sm.7044,Business and f property
Cade:The C improves hemor,law
$ dornot
such roan owner or property whonemporees,prrtedthatand OCC.GROUP RES.UNITS
EEE wprovesuch work tintenedorough his fferedownemIf,how,er,thedthatsuch
Imgrovementsared withendneyearfma fear sale.theowevegthderwill ha or TOTAL: L
Improvementisaold withinooyvarolcompletbn,eheownerW 0derwlll have
tl,l_tluudenof proving that M did and Wild or Improve for purposeof sale.). QTY. PLUMBING PERMIT FEE
LJ 1,as owner of the property,am exclusively contracting with limmad FLOOD ZONE APN
mntraaors to mmntruct the project(Sec.7054,Business and Proferloru Code: PERMIT ISSUANCE
The Contreaor'e License Law don cad apply to an owner of property who ALTER-DRAIN&VENTWATER(FA)
Wilda or Improvescontracts,thriven,and who contfor such pUo - -
jects with a FEE SUMMARY
a tt�actul.)licensed pursuant to the Contracto/s License Law.
ml am exempt under Sec. B&P C for this moon BACK FLOW PROTECT.DEVICE
OUTSIDE FIWQ
DRAINS FLOOR,ROOF,AREA,CONTI. SANITARY Y N
• Owner Date ftFGEIPTN
WORIIMANmthat COMPENSATION ofDECLARATION FIXTURES PER TRAP SCHOOL TAX Y N
01 hereby orkem that t have o certificate of aonrnt to sp the mf or.. RECEPT#
3800,Lab o(Workers'Comperatlonlouranr eracartlled mpythemeo((Sec. GAS FA.SYSTEM-1 NC.40UILETS PARK FEE Y N
\, 350Q lab C.) RECEIPT#
Policy I— GAS EA.SYSTEM-OVER 4(EA)
Com any BUILDING DIVISION FEEy'
ffccnllod mpy is hereby furnished. GREASE/NDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
ehiied copy is filed with the city inspection division.
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWFRSANTTARY-STORM EA.20mrf. Date
(This section need not be completed If the permit Is far ane hundred dollar
($100)orlyd.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ _
I cerdlythat In the performance of the work forwhlch this permit la Issued,
I shall not employ any person In any manner so as to became abject to the WATER SYS•IEM/TREATING
workar:Compenrtmn Iowa of CallrornIs.Date RESIDENTIALB. PAI
O Z Applicant NEW RESIDENTIAL PLMSQ.FT. ate Rlml tilt
Z O NOTICE TO APPLICANT:If,ager nuking this Certificate of Eaem)rtlon,you
should became subject to the Works m'Compensation provislor of the Labor OTAL:
CCN Code,you most forthwith comply with such provisions or this permit shall be 6 NG .m
LU > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a � IherebyafOrmthat them is a construction Lending agency for the performn - TOTAL; ELECTRIC FEE 2 •7S
D Z am of the work for which this permit is lnued(Sec.3097,Civ.C.)
U O loaders Name PLUMBING FEE
I— Lender'sAddress QTY. MECHANICAL PERMIT FEE
O W Icertlfythatl have read lhisapplicationand statethattheabovelnforrratian MECHANICAL FEE
f11 iscorrect.Iagmatocomplywlthalcity and muntyordlnances and state laws PERMIT ISSUANCE FEES PAID:
>. N relating to building construction,and hereby authorlu representatives of this
a to entero Pon the above-mentioned for Inspection purposes. ALTER OR ADDIO MECH.
~ ?
city
agree save,indemnify an d kkep property
the ity fportioo Date - eceipt#
U against liabilities,judgmenm,man and expenses which may in any way accrue AIR HANDLING UNIT(TO 10,ODO CFM) S TOTAL:
agalro dcityt eanaeaN ne egrsnting dthis permit CONSTRUCTIO TAX
,/3' A ft HANDLING UNIT(OVER 10,000CPM)
Sign ocam/ cat Data EXHAUSTHOOD(W/DUCT) CONSTRUCTIO TAX PAID:
HA7A 15 MATERIALS DISCLOSURE _
Will the applicant rebuilding occupant store or handle hazardous HEATING UMT(TO 100,ODO BTU!) Date Reeei t#
material as deRned by the Cupertino Municipal Code,Chapter9.12,and the
Health and Safety Code Section 25532(a)I HEATING UNIT(OVER 100,000 BTU) OTAL: 3 3Z
F-1Y. 1I No
Willtheapplicant or future building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUAN DATE
which emit hazardous air contaminants as defined by the Bay Area Air
• Quality Management District? BOILER-COMP pEI'DR 100,000 BTU)
4 Y's
azardo❑No
bavereadthehusnuterialsrequimmentsunderChapler6.95of BOMER-COMP(OVER IW,0W BTU)
the California Health&SafetyCade,Sections 25505,25S33 and 25534.I
understand that if the Wilding does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.Fr.
mporuibility,to notify the occupant of the requirements which moat be met
pI. ed a Cert icate fOccupa acy. P A
P
-�r2
nem or autho da Date )SgUE
TOTAL:
OFFICE COPY Cll r Uj CUNt„f liru