23214 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building project Identification PERMIT NO.. �a
Building Addms: 2 JGfL�
J 2 1 A
l9AVE
one: A A
E6'r& LI/✓ CITY OF CUPERTINO-BUILDING DIVISION _ CJ Z
• Co WAName: / Lic..Nn: APPLICATION / PERMIT
I)AAAAIAI /n/ Q97 BUILDINGELECTRICA[.PLUMBING-MECHANICAL CATEGORY CONTROLN
Architect/Engineer. Lie.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PLRMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Cha pier 9(conmienc APPLIANCES-P.MDENMI, JOB DESCRIPfiOtr-')
ing with Section 7000)of Division 3 ofthe Business and PmfesslonsCods,and my .I/
license Is in full fo a end effect. rNl�f t
LlcenagCW _ J PANELS
CCna
ctoQ//✓G Ver,
Date
ARCHITECT'S DECLARATION 301-1000 AMPS
02 I understand my plans shall W used as public records. OVER1000AMPB SQ.FT.FLOOR AREA 5/SQ.FT.
w O SIGNSELECTRICAL
V o) Licensed Prolesslonal
Q, P
OWNER-BUILDER DECLARATION SPECULCIRCUT/MISC
IhcrebyafOrm thatlam ezempt lromlhe Contractor's License law fns the
following...(Section 70315,Business and Pmfessions Cade:Any city or TE P.MEfERORPOLEINST.
county which requiresa perenittoconstruct,alter,improve,dennish,or repair
gy[9.n anystructure prlorto its issuance,also requiresthe applicant fwsuch permit to POWER DEVICES
ES itl file a signed statement that he is licensed pursuant to the provisions of the
OWE Contractor's License Law(Chapter 9(.rneencleg with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
30 sto.3ofthe Businassand Profemlom Code)orthathebexem therefmmand
Hy.'S the basis for the alleged exemption. Any violation of Sectio70315 by any OUTLETS-SWITCHES-FIXTURES
65 applicant fora permit subjectsthe applicant to a civil penalty of not nnrethan
c, Og five hundred dollars($500). NEWRESIDENTIALELECTR FT.
69, SQ. STORIES TYPECONSTRUCTION
Q 7< ❑I,as owner of the property,or my employees Is with wages r there sole
mm(Sec.70K Business
usBothe work and thestrotture b not intended or offend for
O sale(Sec.761y Buslrau and Pro(esslora Code:The Contractors License law
$g does not apply to an owner of property who Wilds or improves thereon,and OCC.CROUP RFS.UNITS
who docs such work himself orthrough hisownemployees,provided that such
Improvements are not Intended oro0ered for sale.I(howeveq the W ile ing or TOTAL:
Improvement u sold within oneyearofcompletke,the owner-bulkier will have
m$.htben of proving that he did not baud or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
"L as owner of the property,am exclusively..trading with licensed PERMIT ISSUANCE .UO
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractors License Law does not apply to an owner of property who
Wilda or Improves thereon, and who contracts for suck poojects with a ALTER-DRAW 4a WATER(EA)
dor(s)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
151 am
SUMMARY
am exempt under Sec. B k P C for this reasonOUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
. Owner Date RF-CF7IT X
WORKMAN COMPENSATION DECLARATION FIX.PURFS PER TRAP SCHOOLTAX Y_ N_
❑I hereby aftlrm that I have a certificate of consent to ulf-Nsure,or RECEIPT X
certificate of Workers Compensationinsurance eea certifiod.pythermfeke . GAS EA.SYSITM-1 WG.4 OUTLETS PARK FEE Y N
3800.[ab CJ ::ff1�X
p fiI X �/((C M�Q70t0[� GAS EA.SYSfEI.1AVER4(EA) RECEIPT
Cam any AMS% sTAFFA BUILDING DIV]SION FEES
[�Cemfied.pyla hereby furnished FLANGE-IECK FEE
rvlCenlfie ccpylxfiled with led city inspection division. CREASE/INDUSfRL WASTE INTERCEPTOR
NZ
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.300FT. Date Rettti tit
(I'hlssection need not W completed If the permit is forom hundred dollars
(1I0()orlesc.) ' WATER HEATER W/VFi"TT/ELECTR 7s SV ENERGYFEE Y_ N_
1 mrdlythat N the performance of the week for which this permit is blued,
1 shall not employ any person In any manner so as to become subject to the WATER SYMEM/TREATING
Workers'Compensation laws of California. Date PAID
OZ Applicant NEW RFSDLNRALPLMB. �FT. Date Recei tN
Z z NOTTCETO APPLICANT:U,after making this Certificate of Exemption,you
W should become subject to the Workers Compensation provisions of the Labor TOTAL:
Cade,you most forthwith comply with such provisions orthis permit shall be - BUILDING FE"
seemed revoked.
W
_ CONSTRUCTION LENDING AGENCY SEISMIC FEE
d I hereby affirm that there Is a construction lending agency forthe perform TOTAL: �]a,� ELECTRIC FEE
M Z arm of the work for which this permit is Wued(Sec.3097,Civ,C.) PLUMBING FEE
u O lender'.Name
f Icnder'a Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
Il U Icertlfythzt l have read thbapplicatio...d Yatethatthezbove Information
O W iscorrect.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} 0. relating to building construction,and hereby authorize representatives of this
N cit to entero the aWve.mentloned f inspection ALTERORADDTOMECH. Date ReCel [M
H Z Y poo P'ope'ry lthe
P^rWser P
V _ (We)agree Is,save,Indemnify an d keep harmless the City y Cupertino AIR HANDLING UNIT CIO I0,000CFM)
galnstllabi0tityin meque nand ex sea which mryin anyway accrue SUBTOTAL:
1 In ns a aft '.tin his frmlt AIRFIANDLINGUMT(OVER10,000CFM) CONSTRUCTION TAX
Signature of A!pplicant/CcAnctor Z Dale EXHAUST HOOD(w/DI1C7) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS D]SCLOSU RE
Will the applica nt or future building occupant store or to fid le hazardous HEATING UNIT(TO 100,000 BTU) Date ReceI tit
material as defined by the Cupertino Municipal Code,Chapter 9.13,and the
I Iealth and Safety Code Section 25533(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes No
Will the appaesm or future Wilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP(3HP OR 100,0(D BTU) n p ' D
Yrs (.No T N
4have is Heathe lth
Chapter I5
of BO LER-COMP(OV(OVER BTU)
the Wlitomt Health building
Code,rot
5SI3and,that I
understand thatn notify
the orcupoes not erequI menta which
that it met NEW RESIDENTIAL MECN. � JAN 2 9 1992
res,,'tom ity c notify the occupant cc the requirements which must be met
prior to Issuance ora Certlticate otOmpanry.
C I C
w V_C j�UCL(
Owner authwiuTOTAL:
d agent Date ISSUEDBY_
OFFICE COPY