23830 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY,
building Project Identification PERMIT NO.
Building Address: 23830
/ 9vso ,IevalArIeIvev&*r Awn .
Own Isane: A
Q (�^,, CITY OF CUPERTINO-BUILDING DIVISION
dot's Name: Lic.N. APPLICATION /PERMIT
BUILDINE-ELBCTRICALPLUMBING•MECHANICAL CATEGORY CONTROL N
rc Engineer. LIc.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add,-50 W �� PERMITISSUANCE V EJ 1:1 ❑
LICENSED CONTRA OR'S DECLARATION �.I
IM1erebyaffbmthat l am Bcensed under pmv1donsof Cbajeer9(ourramenc, APPDANCE -RESIDENTIAL JOB DESCRIPTION
ingwltb Seddon 700aol Dlvlslon3ufthe Bualncasand ProfessionsCode,aad my / /
license is In(ugfRLcepnd effect A991 5 PANELS n _�o /•7Li/ C,
License Chss —Coen r//}"� /
Date Gontrsdor mi1000AMPS
ARCHITECTS EC ON
q�q�vv 0O pZ (understand my plats shall be used as public rccmds OVER 1000 AMT'S SQ.FT.FLOOR ARTA 5/SQ.FT.
Fi U g Licensed Professional SIGNS ELECTRICAL
H Q OWNER-BUILDER DECLARATION
H�L7 SPECIAL CIRCUIT/MISC
L. a owing raffirmlhatlamexempt fem,31.5,Bsis.a Contractors Lknam law fort he
Z9 pp following reason.(Section 7.115,Bualness and Pro(eulons Code:Any city cur
KV'F'W countywhichrepimapert tiommtmd,altenimprov demoldh,urmor TFMP.METIX OR POLE MSI.
POWER DE
nyetncturc prbrto ltaLwance,aLw rcqulrcetheapplicant(oreuch pemdtto VICES
ry1 file a signed statement that he is licensed pursuant to the provisions of the
3w Contrsd.e.Lie...Law(ChapterI(commuming with Section 7000).f DiA- SWIMMING Ii70L ELECTRIC VALUA
SOS don3 of the Budesssacad Professlom Code)orthat he is exempt therefromand
< the baste for the alleged exemption. Any violation of Stolon 7031.5 by any OUTLETSSWITCHFSFI%TURFS
applicant for a permit subjecrsthe applicant to a civil penalty of nut mare than
live hundred dollars($50(f. NEW RESIDENTIAL ELECTR SQ.Ff.
�n ❑I,a,owner of the property,or my employees with wages a,their sole STORRN TYPE CONSTRUCTION
compensation,will do the work and the structure is not Intended or offered for
0 sole(Sec.7044,Business and Professions Code:The Contradoes License Law
$$ does not apply to an owner of property who builds or Improves thereon,and OCC,GROUP RFS.UNITS
who dres.uchwork himself orthm sigh hisawnemployees,provided that such
improvementsare not Intended reoffered forsale.If,however,thebuildingor - TOTAL:
improvement issold within oneyearofcompletbNtheowner-bulMerwill have
a tIVLtnuden of provingthat he did not build or improve lorpurpme ofsale.). QTY. PLUMBING PERMIT FEE FLOOD TINE APN
U S as owner of the property,am exclusively contracting with licensed PERMIT15SUANCE
contracture to mnstrud the project(Sec.7074,Business and Professlom Code:
The Contractor's License Law don not apply to an owner of property who ALTER-DRAIN k VFM-WATER(EA)
Wilds or Improves thereon,and who contracts for such pwiscs with a FEE SUMMARY
` m•B[Iador(a)licensed pursuant to the Contractor's License Law, ,AIX FLOW PROTECT.DEVICE
IJ I am exempt under Sec B k P C for thin reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Dee RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL VAX Y N
QI hereby dfirm that I have a certificate of consent to self-inmrs,m a REMOVE�
mdlBot.ofWurken'Comper timlmumnmmamrtlfwmpythercof6ec.
3300,Lab C.) GAS F.A.SYSTEM-1 MC40UTLETS PARK FEE Y_ N
NRECEIVE N
CompanyGAS E.A.SYSTF2d-OVER4(EA) BUILDING DIV
ISION FEES
FIr,ortltled copy is hereby fumlahed. CREASE/MDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
ertNed copy b filed with the city inspection division.
CERTIFICATE OF EXINIPT[ON FROM WORKERS' GRE-ASE7RAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200Ff Date Recei t#
(ThlssMion need cad be completed of the permit Is(mane hundred dollen
(S101))rr lean) WATER HEATER W/VENT/F2.ECTR ENERGY FEE Y N
ce
I rtify that lathe performance of the work furwhich this permit is leered, —
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING a Workers'Compensation Law.of California. Date PAID
licant
-
z ZO N07ICETO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQFr. Date Remi t#
should became subo to the WorkersCompensation provisions of the Labor TOTAL:
N Code,you at forthwith comply with such provisions or this permit shall be BUILDING FEE
W 9 deemed revoked. L99 I
(LCONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency for the perform ELECTRIC FEE
Z ance of the work for which this permit le;issued 1Sec.3097,Civ.C.) TOTAL:
U O Lender'.Name PLUMBING FEE
ly F- Lendcr.Addmss QTY. MECHANICAL PERMIT FEE MECHANICAL PEE
O W Icedifythatlhavercadlhisappllmdonandstatothattheabovelnformatlon
1 I,crrmd.7 agree to complywith all city and county ordinances and date laws PERMIT ISSUANCE F- -
10i,
•E
�. N relating to building construction,and hereby authorize representatives of this
1—
city Z to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADDTO MECH.
(We)agree and an d keep harmless the City of Cupertino Date Receipt#
V .,.Inst 11s,csandexpensawhlchmaylnenro
ywayacce AIR HANDLING UNIT(TO to,"CFM) SUBTOTAL:
aid u a of the gr&nting of thls pem lt.
s/ AIRHANDLINGUNIT(OVER IQ000CFM1 CONSTRUCTION TAX
mot Icanl/Contractor Date IXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willthe applicant orfuture building occupantetom rrhandle hazardous HEATING UNIT(TO 101),ODO BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER ILO,OOD BTU) TOTAL:
❑Yes No
Will theappllcanlor turc building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISS'A TE
which emit haeardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP OHP OR 100,0(10 HIM
4Ym ❑❑No 't
haveneed the haadauamaleria6rcqulrementsunderChapter6.95of BOILER-CONP(OVER 100,000 BTU) JUN 1992
the Callfemda health 4 Safety Code,Sections 25Sa5,25533 and 25534.1
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIALMECH. SQ.17 CI'II-ut-'UUrz,Iim--
responsibility to notify the occupant of the requirements which resat be met
prior to Issuance M a Certificate of Occupancy. ////�` �/J /'
Owneror authorized agent Date TOTAL: ISSUED BY4 A&e-el
OFFICE COPY