23686 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ed IdentificationPERMIT NO.
BuildingAddress: -3 ��� r��� 23686
we ante: one:
1' A A
Vl0 .5 7�J�P-q 5'f3 CITY OF CUPERTINO-BUILDING DIVISION
Cr Name: Lie.(� APPLICATION I PERMIT
eS r _3 OJS BUILDING-ELECTRICA4nLTMBING-MECHANICAL CATEGORY CONTROL If
Archlted/Engineer. Llc.Na.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Adchn-203 0_F61c/ S PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION _T EJ 0 El
I hereby affirmthat l am licensed under provisions of Chapter9(mnermc. APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwhh Section 7000)of Division 3 ofthe Business and ProfesgonsCode,and my �`e�',jtiRJ
license is In full orceand effect. PANELS
Lkcnx lass LIc.N
Date Contrader UPT0200ANTS
Ina S CLARATION 701-1000A.MPS � �s
re0 Z I understand my plans shall be usca4s public records. OVER 1000 AMPS SQ.ET.FLOOR AREA S/SQ.FT.
O
C
C d() Licensed Professional SIGNS ELECTRICAL
<Gw OWNER-BUILDER DECLARATION
I-n Fn WSPECWLCBRCUIT/MLSC
following
7MImptlromthed Prtrfinedo License Law fort he
ZO_'-4 (oilow(ng reason.�ndlon 7Qil S,Business and Profemiom Code:Any ssty or
O Z E, TEMP.METER OR POLE INST.
F�ppp counrywhich rcqulresa pemdt tocontmd,alter,lmprove,demolish,orrepair
q j anystmdum priorto its lseuance,also requires theappliant forsuch permit to POWER DEVICES
LL r<a Ole a signed statement that he Ls licensed pursuant in the provisions of the
$3p� Contradora License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
F„ gon 3ofthe Buslnemand Profeslon Code)orthat he Aexempttherefromand VALUATION
Q y1 the basis for the alleged exemption. Any violation of Section 7031.5 by any
appu nt fora permit subjectatheapplicamtaadvil penalty of outmorethan OUTLETSSWITCHESHXTURES I�^l Is
100
Ove hundred dollars(5500). N'EWRFSIDENTIALELECIR SQ.FL /
..�n ❑I,as owner of the property,or my emp My with wages r their sole
STOW6 TYPE CON'SIRUCTION
�7a compensation,BusinesandkandthestCde:TheCintende's License
5 O sale(Sec 7044,to Businessand
property Code:The orImpoves Liceroe law l'
�S$ does enssueet ly loan ownerofprough hisoWilds nemporlm,provided
vent,and
that such
I OCC,GROUP RFS.UNITS
who doeesurhwork himselorthrwgh hisownemployees,providedthatsuch
improvements are not intended or offered for sale.If,however,the building or Vu
improvement is sold within one yearofcompletion,the owner-bu0derwill have
th mr,lm of proving that he did not build or Improve for purpose of sale.). QTY,I PLU=NGPTRMIb4jeETApD zoNe ApN
LJ L as owner of the property,am exclusively contracting with limned LFRMi7 LaUANCE J!
contractors to construct the project(Sec.7074,Business and Profession Code:
The Conme ori License Law does not apply to an owner of property who ALTER-DRAIN k VFM-WATER(EA)bullets or Improves thereon,and who contracts for such p,jects with a
,,ttRBfTactor(a)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
I_J 1 am exempt under Sec B 4c P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y— N_
• OUTSIDE I'LLS
Owner ECL RECEIPTIf
WORKMAN I have.COMPENSATION DECLARATION FIXTURE_&PER TRAP SCHOOL TAX Y_ N
❑1 hereby mkensaffirm,that I have•certificateInsurance
c o!consent dd o y thereof ora RECEIPT N
certificate ofWarken Compensation Wurance oracertified copy thereof(Sec.. GAS EA.SYSTEM-1 INC.4 OUTLETS
Po�,Mb C.) yl g��P _ PARK FEE Y_ N_
Com any GAS EA.SYSTEM-OVER 4(EA) BUILDINGGDDIVISION FEES
IBM copy V ereed. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
mRed copy V filed withth the the city Inspection division.
CERTIFICATE OF ECEMPFION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARYSTORM EA 200FT cei t#
Date Re
(Thissession need not be completed I(the permit la for one hundred dollars
(S100)arfy,th WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
(certify that in the performance of the work lorwhich this permit lsbmed, —
I shall not employ any person in any manner so as to become subject to the WATER SYSDIM/TREATING
Workers Compensation Laws of California.Date PAID
O Z Applicant
Z O NOTICE TO APPLICANT:If,after making this certificate of Exemption,you NEWRFSIDFNfIALPLMB. SQDate te Remi t#
should become subject to the Workers'Comperetat ion provisions of the Labor~ TOTAL:(/) Code,you moat forthwith comply with such peovision permit this pedt shall be
W > deemed revoked. BUILDING FGE dU
d p CONSTRUCTION LENDING AGENCY SEISMIC FEE
Iherebyaffirm that there Is a construction lending agency for the perform- SETS ERIC FEE
50
Z mce of the workfe which this permit he Issued(See.3097,CIv.C.) TOTAL:
02 Landers Name PLUMBING FEE
LL F- lander§Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W ImrtilythatlhavereadthbappllcaHonandrtatethat theabovelnformation
1 Is correct.l agree to comply with all city and county ordinances and gate laws PERMIT ISSUANCE FEES PAID:
} W relating to building controdim,tul hereby authorize representatives ofthis
F Z city to enter upon the above-mentioned property for WpeMon purposes, ALTERORADDTOMECH.
_ (We)agree to as",indemnify an d keep harmless the City of Cupertino Date Receipt#
against liabilities,udgments,cogs and expenses which may in anywayacerm, AIR HANDLING UNIT 10,IXp CFM) SUBTOTAL,
agat tui C' In naequenceo granting ofThls emit
/`' AIR HANDLING UNIT(OVER IQ000CFM) CONSTRUCTION TAX
Sig natureofA pliant/Cont dpr Date E
XHAUSTW/DUCT) CONSTRUCTION TAX PAID:
H1'aRDOUS ATERIALS ISCLOSURE
Will the appllant orfuture dullding occupant store or handle hazardous HEATING UNIT(TO 100,000 BN) Date
material as defined by the Cupertino Municipal Code,Chapter 9.q and the Revel t#
I Iealth and Safely Cade Section 25532(a)7 VER 100,000 BlT))Yes INo TOTALWill the applicant orfuture building occupant use equipment or devices (SINGLE RESID) I$$UANGE DATE
which emit hazz rdous air contaminntaas defined by the Bay Area Air ��qyCQuality Management Distrid7 MP OFD'OR 100,000 BTU) Ifs n B 6!
F1 Ya'
R,n A
have read the hact mrterlals requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health k Safety Code,Section 25505,25533 and 75534. I
understand that if the building does not currently have E meant,that it is my NEWRFSIDENDALMECH. SOFT. MAY 15 1992
responsibility to notify the occupant of the requirements which most be met
prior to issuance of a Certificate of DccoIts ncy.
Cal(V I)AGI LyCn�}rV
Owner ormmnris<d agent Date ISSUED BY. `� I6
TOTAL: : mss/-al/-eR—fV1
OFFICE COPY