23050 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
s
Building Proed Identification PE(MPTNO.
B°�"g Add ' 23050
ext cOF CUPERTINO,BUILDING DIVISION
®ContracldINa LIcN. APPLICATION /PERMIT
16 'Q BUIIAING-E.ECTRICALPLUMBINC-MFLHANKAL CATEGORY CON ROLY
n7
" '� Q ELECTRICPERMIT FEE
G BUILDING PERMIT INFO
Address 1:1 ❑
PERMITISSUANCE
LICENSED lic..d..de,pONM DECLARATION
I hereby
at(Um H)of D( kmacfthell pravMoval ss!... de,..dm APPLIANCES JOB DE'S
Ingwlth5eebn7Wt7)olpWelon3o(1he Riuinea+and (evlonaCade,and
11¢mebin/uBjjotq feet 3 PANES
D.t. Class Contractor
I
Dete Contnnar
ARCHITECTS IARATION 201-IODD AMTS.
7
1:2.1d my plana shoU be used m public recerda. OVER 10DO AMPS SQ.FT.FLOOR AREA f/SQ.FT.
OC SIGNSEI.ECTRICAL
LkxvN Pmfeebvl
OWNER.BUILDER DECLARATION SPECIAL CIRCUIT/MLSC
71.., G Thereby affirtnthat l..exempt from the Cordraeorb License law for the
following reason.�ectim 70315,Business and Professions Code:Any city or
TEMP.MElF7t ORIOLE INST.
K =`
county which require apermit tocamtrun,alter,lmprove,derrolbh,orrepair
q`'O anystruau¢prbrto its favurice,abo rtqubentheapptlunt for such permit to POWER DEVICES
file a signed statement that he Is licensed pursuant to the prmtsbm of the
3 Contractor'sLkerse Law(Chapter 9(commencing wO Section 7000)of ppbS1yU,ggNGIW' E.ECIRIC
abn3ofthe BustnessandPMessbm CMe)orHuthebexempttherefmma" VALUATION
G.o the W,b for the alleged exemption. Any violation of Section 7TU,5 by any
epph.ntforapeOUD.ti 1SSWI.ICFI6F7Xfl1RE5 �?
mdtsuboM the.ppB .tmadullpenshy ofnaemorethan VO�T
nue hundred dollars%5M.
❑I,as owner of the property,or my employee with wage u thalr Bole NFW R®DENIAL ELFC7R STORIES TYPECONSIRUC_TION
comperuomov,wW nb dothe work,and the sUuure not intend"or offered for
Osalc(St.70W,Bwirsseand]ivfmlov Code:The CwMract.e.License law
S$ don wt apply to an uwnar d property who build&or Improves thereon,and
^ who domsuch work himself¢thwgh M&own employee,provded that such OCCCROUP RFS.UNITS
ImprovemeNa ase not Intended oroffered!«sale.If,however,thebuilding or TOTAL
improvement is ld wkhlnonayearofmrmplecbr4tie mwner4rufiderwW have
tkajZurden of proving that he did not bund or Improve for purpose of saie"). QTY. PLUMBING PERMIT SFE
L_I I,as owner of the property,am exhoWely contracting with licensed FLOOD ZONE AI'N
mintranor&to conatrud U,cproject(See 7044,Business and Professions Code: PERMIT ISSUANCE
TFe Contractor's Li erre Law doe not apply to an owner of property who AL.IFA-DRAW k VENT-WATER(Ek)Wilds or improve thereon, and who contracts for such p,)mus with a FEE SUMMARY
c�(r+dw(il llmixd Pursuant to the Coutredes Lireree Law. BACK PLOW PROTECT.DEVICE
LJ 1 am exempt under See. B k P C for thio reason
Date DRECEIPTO
DRAINS FTAOR,ROOF,AREA,GOND. SANITARY Y N/3wnOwn, RRECEIPT Y
WORWORKMAN COMPENSATION DECLARATION
TION
❑I hereby affirm that I have a certificate of consent to&elf-ins¢ ora FDCFURES PER TRAP SCHOOL TAX Y N
remWote ofworken'Compers.tim Insurance ma certified copy thereof ISM REC=Y
3800,T �^ 7—/6���,-. �/ CAS G.SYSIFAI.1 WG40ITILEfS PARKME RECEUTY
Pdiryl .— / '7 GAS G.SYM12A-OVER 4(GI
Cry �1 f BUILDING DIVISION FEES
Certified copy is hereby fumbled. CREASE/WW
DUSrRL WASTE TEtCETIOR PLANCHECKFEE
XcertNcd copy b filed with tie city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCE MWER,SANITARY-STORM FA NpFT. Date Refi'i ttl
(Tits ec<bn neM mat be,completed ittM1e permit is(or one hundred dollars
R10 ) fyt.) WATER HEATFRW/VENT/ED= ENERGY FEE Y N
Imrtifythat tithe pedomun¢ofthework(orwNCM1 tM&pemdt bleu",
I&ha0 not employ any person N any manner so u to beeome subject to the WATER SYSITU/TRGTING
workeri Compematfo.Iaw&ofC ff.la.Date PAID
-
z= Applicant NEWRESIDEMP
IALLIdB. SQFF. Date Recut tit
ZO horsesTO APPLICANT:If,aher making thio Cerrfkateof Exerpt Nou
y
Fshould become subjct to the Worken'Compensation io vium of the Labor TOTAL
N Code,youm fwthw hmmplywltheuchprovbbnaorthbpemdtshallbe
LU ] - deemed rooked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
Il Ihemby.Rbm thatthert baconstmctlou lendingagerryforthe perfomt TOTAL: ELECTRIC FEE
Z an.of the workfor which this permit b issued l$ec 30 Y/,CN.C.)
02 I<nder.Nam,e PLUMBING FEE
LL I— Lena,,.Addmes QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I¢rti(ythatlbawmadthbappliortfmard statetattheabovebmtim
dou
bcormtt.I agmetocwmplywdhW drys"courtyordinan¢&and state lawsPERMIT ISSUANCE FEES PAID:
} 1 relatingmro
tobuilding cotctioo,.rd ve
hereby.whortce representstlofthi&
FN cltyto enterupon the above-mention"Property for inspection purposes, . ALTERORADDMMECK
Z (we)agree to save,wemwfy an d Yeep harmlew the City of Cupertino Date RecCl t#
V ,g,wt BablBties,jud,ments,costs sed expense which may N any way.cmue AIR HANTILING UNIT(170 1000 CFM) SUBTOTAL:
ago Inst said City In.meq.e.of tie gnrding of this permit
AIR HANDLING UNIT(OVER III"CFTO CONSTRUCTION TAX
Signature of Applicant/ContractorDate F 125r HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARIIOUS MATERIALS DISCLOSURE
Will the.pplkard or forum Wilding omv part,tore.,handle ha>amlous HGTWCUMT(YO1m,000BTU) Date Recei 1M
material as deflned by the Cupertino Municipal Code,Chapter 9.1;and the
Ile.hh a"SafetyCode Senior 2S532(.)? FffATING UNIT(OVER IW,"BTU) TOTAL: bilisc
❑ Ye No
Wllltheapplhm'¢ wmb,uildingoaupantuwequipment«devicesVENTILATION FAN(SINGLE RESID) ISSUANCE DATE
whichou
emit ha ards air comanvb
tlnasdeBred by therc
Bay Aa Air
Quality Mavgemmt District? BORER-COMP(3HPOR 100,000 BTU!) P A I D
Ya No
have read theM1 oue materials requirements under Chapter&95 of BORER-COMP(OVER 100,000 BM
i the California Health&Safety Code,SedWns25505,25533and 25534.I dpi/ 271991
understand that if the building doos not k currently have a tenant,that It my NEW RESIDENTIAL MECH. SQ.FT
maponsibelty to noilly the occupant of the requirements which must be m t
prbrto is/oJ�r..f.Cctlfiatcof aruy. _ G[ CATTY OF CIU-PRI�Et I
17
gen � �late OTAL L
ISSUED BY;
OFFICE COPY