23353 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES = USE BALL POINT PEN ONLY
I Building Pro'ed Identification I PERMITNO.
-9 Bolding Address: 23353
'
Al, S e
eters ossa: one:
U SO CITY OF CUPERTINO-BUILDING DIVISION Qr
C traeter.Name: rya J Lk.N APPLICATION I PERMIT
�'v a BUILDING-ELECIMCAL-PLUMBING-MECHANICAL CAIECARY CONTROLN
ArNItect/Englacer. Lie No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address,
PESbITISSUANCE i
LICF.NS It CONTRACTOR'S DECLARATION
Ihth Sb on7Offlurn lutlam Bcm3oftheunder idr andPmfessions9(mmmm APPLIANCES-RESIDENTIAL j OB �1
ingwithStfon7000)e/Divlslon3afriss Bupnessand ProfnponaCode,and m Jr
license is In fug fppp}���and efft. �YS4/a PANELS ��
License Ch /JI' GeM
Date__ ContractoHITECr 201-1000 AMPS
UP TO 200ANIPS
Ans shag CPS DECLARATION
Fq±�2 IuMerstand my plana sisal he used as public records. OVER 1000 AMPS SQ.}T.FLOOR AREA S/SQ.FT.
E Licensed Prefeaslanal SIGNS ELECTRICAL
t<� OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC
Zt, DI IherebyafBrmthatlamexemptfromthe Contranor'a Llrense Lawfwthe _
pp folowing reason.(Section 70115,Business and Prof.ssW .Code:Anyty or tl
Oy TEMP METER ORIOLE MSI.
P� muntywhich requlmapermit romosWct,alter,improve,dennlbh,orrepalr
< aoystructure priorto its issuance,aborequir athe applcantfor such permit to POWER DEVICES-
U file a signed statement that he is licensed pursuant to the provisions;of the
O w1- Contnctori License Lw(Chapter 9(commencing with Section 7000)of Divi-
F•�O:} alon 3 ofthe Buslnessand Pro(eniouCode)orthat he b exempttherefromaM SWIMhINCIWLELECI'RIC VALUATION
0.•77 the basis for the alleged exemption. Any violation of Section 7MIS by any OUTLETSSWITCHES}TXTURFS r O
applmnt fora permit subj tatheapplno cant toa dAl penalty of nmore than
five Nuns ed Ownerlers fthepr. SQ.Fr. STORIES TYPE CONSTRUCTION
C"c NEW RESIDENTIAL ELECTR
❑I,as owner of the property,or he employees n with wages ffere cob
.Is&c.winponsa 044,will dothe
and ri�Pr and ions Code:
The cont endedactoe or coffered for
O dais(Sec.ppy to Business and Professions Code:The or impoves there, law
$ does not apply to rk owner of property who n builds or Improves thereory and OCC.GROUTS RES.UNITS
who docasuchwork himseR orthrough hisown employees,provided that such
Improvementa are not Intended oreffered for sale.If,however,the building or T
(mprovementbsoldwithinoneyearofcmnplet(on.theowner-bullderw lhave
the burden of proving that he did not build or improve our purpose ofsele.). QTY. PLUMBING PERMIT FEE
n;as owner of the property,am exclusively contracting with licensed FLOOD TONE APN
contractors to construct the project(Sec.70"Business and Professions Code: PERMIT ISSUANCE _e
The Contractors License law does not apply to an owner of property who ALTER-DRAIN&VENT- ATQ4(EA)
Wilda or improve thereon, and who contacts fee such project,with a FEE SUMMARY
�yt.I+0r(O licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.D
LII am exempt under See B&P C for Nb reason
&rfr, OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,ODND. SANITARY Y N
• Owner ECLDate REGEIPI'N
WORK MAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N
❑I hereby affirm that I have a certificateInsurance
of consent to opytnereo or RECEIPT.N
3800tILet,C.)cate of rkcn'ComperuatlOnlosurance ora cepl(led mpythereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS r� PARKFEE Y_ N
Policy If RECEIPT M
Com any GAS F.A.SYSTEM-OVER 4(FA) BUILDING DIVISION FEES
Cerllned copy is hereby tthcity
e ty W pectien division.
e ci
❑CertNed copy b filed with the CREASE/INDUsrnL WASTE INTERCEPTOR PLANCf IECKFEE
CERTIFICATE OF EI(EM PT ION FROM WOR KERS GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200171• Date RCCCI t#
CTMssection need not be completed If the permit Is forooe hundred dollars
Cilll)mina.) WATER HEATER w/vENT/ELFCTR ENERGY FEE Y N
I certlythat M the performance of the work forwhich this permit is Cwaed,
,I shag not employ any person in any manner.. 'bled to the WA.1.Qi5YSI.QA/.I.RFA.DNG- PAID
Waken C n hlicantJjR G ! h�pate 7 Z.
Z Z NOITCETOAPPL�ICANS:If,a CYgtUhb Certltl a Of Esemptlon,you �w RESIDENTIAL PLMB. SO.FI. Date RCtCI 1#
0 should become wbkctto the Workers'Compensation provisions of the Labor TOTAL:
W
Code,you moat forthwith comply with such provisions or this permit shall be BUILDING .—
W � deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
IL Iherebyafil that there be construction lending agency for the perform ELECTRIC FEE
7 Z onceOfthe workferwhlchchb permit b Issued(Sec.3097,CIv.C.)' T
(� O leMels Name PLUMBING FEEU.
F Lender.Address QTY.I MECHANICAL PERMIT FEE
O W lcedifythatlhavereadthlaapplimtlonandetatethattheaWwinformatlon MECHANICAL FEE
1 bcomect.lagreetocomplywithelltltyand muntymcit.ancesanddemlaws PERMITISSUANCE �' FEES PAID:
>- N relating to building construction,and hereby authorize representallves ofthb
[— city to enter upon the abmecnantlooed property for Inspection purposes. ALTFRORADDTOMECH.
Z
Z (We)agree to seve,Indemnity an Of keep harmless the City of Cupertino Date ReCel t#
against liabilities,judg ,cepa and expenses which may in anyway accrue AIR HANDLING UNIT CTO 10,000 CFM) SUBTOTAL:
agabstest CII ince euxofthegrantingofthiapenn 1.
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
gnalurcof Appll nt/Contractor Date EXHAUST HOOD M/DUCT) CONSTRUCTION TAX PAID:
AZARDOUS MATERIALS DISCLOSURE
Will thearant or to ore building Occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCCCI 1#
material asd nM by the Cupertino Municipal Code,Chapter 9.IZ and the
Health and Safety Code Section 2E532(e)I HEATING UNIT(OVER IW,000 HIM TOT20C ft
1414
Yn MN.
llthe applicant orfuturs Wilding Occupant use equipment or devicesVENTILATION FAN(SINGLE RESID) D ISSUANCE DATE
which emit haardous air mntamimnt.cue defined by the Bay Area Air
Quality Management DisMct7 BOILER-COMP OHP OR 100,0(*BTU)
4YesNo
havereadthe baea( usrrulerlabrequirements under Cha pter6.95of BOILER-C'OMP(OVER100,000 BTU) pp
the California Health&Safety Code,Sections 25505,25533 and 25534.I A
understand that if the building don not currently have a tenant,that it Is my NEW RESIDENTIAL MECH. SQFT
responsibility to net ily the occupant of the requirements which must be,met
prior toauanceofa atootOmpanry.' R 992
f 'f
Owner orrauthorized agent agent Date 6q[IED
TOT �
OFFICE COPY
H � M
T o �:• , d rJ o M � rn c
e� �Lu + � o
Q cr
o � LA
111 � J Z � � 3 i * •�'
Q �
Z
2 u N J OILI
cr
T
a
x
CL
cz3 w
at.
W
�
_ ,J
i
mo N
4 ',nIWna
3
C4.
V 0 � Z Em nc'sa `
t /� M 3 C� n � cWi `p gmaoos
•:J W j60
E E
2 d cY _N Y yyo�. o N o
Lamm
aJle+����iii o � � y n...