23872 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildin Project Identification *x.230 t PERMIT NO.
Build Ing Address:
23872
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�YJ4TA/s Qoft MW-&W. JU-it R-24. CITY OF CUPERTINO-BUILDING DIVISION / /y
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c�ra�°raNane: Lic,N. APPLICATION I PERMIT aV
r. �/� BUILDINGELECTRICALPLUMBING-MEC NICAL CATEGORY CO
Architect/EngineeLk.No:
QiYELECT IC'PER FEE BUILDING PERMIT INFO
Address ,S`�.1,(aY,�b' yMM FERMITISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby dfirmlhat l arms Bccosed under provisions of Chapter 9(commenc APPLIAN ES DE JOB DGSCRITION
Ing with Section 7000)ot Diviste n3 of the Businessand ProfessionsCudq and my
license is In full force and died.
Liana Clam Lk.N
Date C°ntrador
ARCHITECTS DECLARATION I AMPS
QZ I understand my plana ahaB housed as publlcrecerda <` I000 PS SQ.FT.FLOOR AREA $/SQ.FT.
CO
[� Licensed ProfemlorulSIC EL C yy � �/Aw�-))
—�
�14�3 OWNI:R•BUILDER DECLARATION IA UIT/MISCJ7 0 ' a[[�vJJgq��
Z. IherebyafBrm that lamexempt fromthe Contrador'.Li...Lawforthe --. J
p following reason.(Section 70315,Business and Pmfemlom Code:Any city or r
rH5 county which mqu men a permit to com ud,alteq improve,demolish,or repair P.MEM OR POLE SI.
nystructure pdorto its hatance,aLsorequirestha applicant forsuchpermfuo POWER DEVICES
file a signed statement that he Is licensed pursuant to the provislom of the �
3 w Contractor.License Law(Chapter 9(commencing with Section 7(1(p)of DIv4 PfATE
QO2 don 3o(the1=ssand ode)orthathelsexempttherefromand SWIMMING IA70L ELECTRIC VALUATION
the baa.for thea aemptlon. Any vI.IaH,n of Section 76115 by any
G applluntf rmitsubjects the applicanitoa civil penalty ofoot morethan OIJILEISSWI7CHESFlXTURES l
live red dollars(5500).
NEW RESIDP.NTIAL ELECTRSQ.Ff.
�n I,an owner of the property,or and he employees with wages r their sok STORIES 7YT'E CONSTROCTION
or
5. compen.7044,willdo[be workfenakmstrudurehe Contractors
orcenseL off,rad w
O sale doo (nutapply Boninessand f property
Co builds Contrado2s Lkeme Law
(i'j$$ doss nut apply loanowner offprough whoa emporlmprwmthereatand such OCC.CRCUP RFS.UNITS
0.0.
who does
mants work aenotInteifedor°ughedhis owne.If,ho war,the build Ing or Improvements arenotintendneyearo(comprule.thommvegtilderwdl have
Improvement beold w0hinonoycamfcompldlon,theowner-bu6derwill have
t1,qJ;urden of proving that he did not build or Improve for purpose ofukJ. QTY. PLUMBING PERMIT FEE
u L as owner of the property,am exclusively contracting with licensed FI-OOD TDNE APN
contractors to construct the project(Sm 7044,Business and Protesslore Code: PERMIT ISSUANCE
The Contractors License Iaw does not apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
bu Rds or Improves thered
on, and who contracts for such Inu)es with a
cgtt(Icum(n)licensed pursuant to the Contractor's License Law. BACK PLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sen B k P C for this reason
Owner Date DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
RECEIPT k
WOR KMAN COMPENSATION DECLARATION F0(7lIRES PER TRAP SCHOOL TAX Y_ N_
Ell hereby affirm that I have a affa
rtlte of consent to self-insure,orate,a
REC
arti0cate o(W°rkers'Competuatlon Insurance or a certified copy thereof(Eec.
3800,1ab C.) S CAEA.SYSTEM-]INCA OUTLETS FARC FEE Y N
PolicyM GAS EA.SYSf7]N-0VER4(EA) RECI=- N
CEany BUILDING DIVI ON FEES
Certifi
om ed copy Is herebyfurnished.the city GREASE/INDUSIRL WASTEI EPTOR PLANCHECK FEE 16s, e
❑Certified copy V flied with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WOR KERS' GREASE 7TRAIs PAIDk.
COMPENSATION INSURANCE
(Thlamction need notbe completed lithe permit la(orom hundred dollars SEWER-SANITARY EA.200FT Reeel t s�
($100)rtlfyt J WATER HEATER VENT'/ELECTR E 'R E Y N
1 artily that In the performance of the work(orwhlcA this permit Is bored, —
Ishall not employ any person In any manner so as to become subject to the WATER SY /1REAITNT2
Workers Compensation Laws of California, Date PAID
Cr Z Applicant NEWR AL PCMB, SQ.FT. Date Recei HI
Z Q NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
Fshould become subjectto the Workers'Compeuatlon provisions ofthe Labor TOTAL:
CC N Code,you moat forthwith comply with ouch provisions mthb permit shall be BUILDING ma
W j deemed revoked.
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
I bereby.Mrm that there b a mrotrudion knding agenry forth.perform ELECTRIC
Z ana of the worktor which this permit is Issued(Sm 3097,Cly.C3 TOTAL: '
U O lender's Name �y A�� PLUMBING
LL Q Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICA FEE i�
U ormot.Iagrehavercply is with ailationand dcuntuthat yordinancs andmatela n
W broingtobilding comply with alndtyand countyordinancesand mate FERMI7ISSUANCE �' FEES PAID:
>_ 0. misto tingtoabove optioned reby property
ce Impootexnpurpoa of this
2 city Wa)agree
to sae,indemnify
an
property l s the Cin of Cupers.tino
ALTER OR ADD'R7 MECH.
(We)agree to cove,indemnity an d keep harmless the City y Cupertino DRt6 RCCCI fq
V agalmtIla bllltlro,p 397 m and eapensn which may In anyw accrue AR HANDLING UNIT(TO 10,0[k)CFM) S BTOTAL•
4.
Id City con ce° egrent got thio pe AR HANDWNC UNIT(OVER IO,ODOC71f) CONSTRUCTION AX
10
gna Ap Contractor Dna EXHAUST HOOD(W/DICT) CONSTRUCTION XPAID;
A2ARDOU59 ATBR SDISCL SU E
Wllltheappllcantor 1w bulldin pant store orhandkhaa.rdoua HEATING UNIT(I[)100,ODO BTU) Date R CI
material as defined by the Cupe unlcipal Code,Chapter 9.17,and the
I lea it h and Wary Code 255374)7 HEATING UNIT(OVER 100,000 BTU) T TAL-
❑Yee o .t II�
AO�
Will theapplicam or future build ing tvuby equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE
which emit haurdouaair canmmi sdefinedthe Bay Area Air
. Qu lily Managcrrcnt Distil BOILER-COMP(3HPOR l00,Ofp BTI])
4YC9 JU� .301992
havareadthehaaa ousmateriala requormentsunder Chapter6.95of BOILER-COMP(OVER 100,000 BTU)
the Califomla Health k Safety Code,Sedions 25505,25533 and 25534. I
understand that lithe building does not currently ha veatenanLthatlt Lamy NEW RESIDENTIAL MECH. SQ.FT. CITY / Ct1IIIVU
reapons ' tone"",thea cat of the requirements which sib rrct _
P'. oaf of rtl of Panq
nor° ori t to r7aIdISSUED97mveo
i`
OFFICE COPY