23196 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ed Identification - PRR?vUTNO.
Bulldln Addreaa: - t
23196
w . Penn e:
CITY OFCUPERTINO-BUILDING DIVISION r
Co d.,'.N. APPLICATION /PERMIT
IRVBUILDING-ELECRCAL-PLUMBING-MCHANICAL ATCONTROL p101111, 1 RY
Architect/ Bvers Lie.No
OTir ,� ELECCRIC PERMIT t , FEE BUILDING PERMIT-INFO
Address: - - PERMITISSUANCE - �' '� (OJ ❑ ❑
LICENSED Ia CONTRACTOR'SunderrDECLARATION Lj�l
I hereby
ccronaffirm thatl 1V licensed3fthederpessandsalChapter9ds,and c APPLIANCEB.RESTDEMIAL - JOB DLSCRRTION
Ingwlih SeMan7000)of DlWmon3 ofthe Bumvmand Prolesmov Cafe,and my /
PANk�
license isln(u and d(ai. 3�7 QS 1 • G I r_
Llcenm Clam Lic.p '/ .7 YL j
Deb ontredar '
ANCHITECPSD CLA T 701-1000 AMPS _
q�u Oa ZO I understand my slam ehnB be caro.es pu Bc records OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT,
k IL Licensed Professlovl -- SIGNS ELECTRICAL -
�<6 OWNER-BUILDER DECLARATION SPECWLCIRCUIT/MISC
Zt.., Ihereby affirm that l am exempt fromthe Cora
ntctors License Law for the
pp following reason.(Srctlon 7031.5,Business and ProfemlOns Cale:Any city or
OZ, , TIME.METE(ORPOLE INST.
p� cnYstmmm dortGisp an teavm iilstheapbvntfm.uch,orretto
.aa any.signere examinant
that
he k,Ike-e d pursuant to the rovidh of t e FOWFR DEVICES
rYG U file a actor.statement that he b r9(commencing
pursuant it the provisions of the - '
E,w
Contractor.of the
License Lnd(Chesser9(commencing with Semptherefof and
��0� slon3o(,he Business and Pro(emiOvCadc)orthathebexempt thercfromand SWIMMING POOL ELECTRIC VALUATION '
�' the barb for the alleged exemption. Any violation of Section 7031.5 by any s Ir
O OUTLETSSWI7OHESFIXTURFS
applicant fore per utsubjects she applicant to a civil penalty and morcthen
five hundred dollars($.500). NEW RESIDENTIAL ELECTR
I,as owner Of t he,property,or my employees wit h wages as t heir sole SQ.FL
❑ STOW PS TYPECONSIRUCTION
�7a compensation,will do the work,and the stmdureb not intended or offered for
O role(Sec.7094,Business and Professions Code:The Contradore Lireve Law
does not apply to an owner of property who builds or Improves thereon,and .
CC:: who doessuchwork hineselforshtwgh hisown employees,provided that such OCC,GROUP RF5.I1NIT5
bnprovements are not Intended or offered for sale.If,however,the build Ing or . TOT L
improvement b sold within one yea ro(complellon,she owner-bullderwill have '
tliUvrd an of proving that he did net build or improve for purpose of rale.). Q7y. .;
u PLUMBING PERMIT t"FEE ,OpD ZONE APN
PLUM -' 1' i }T1,as owner of,he property,am exclusively contracting with licensed pFRM77 CE
contractors so constructProfessions Code:the project(See,7044,Business and ProfeCode: '
The Conto dor's License Law does ON apply to an owner of property who ALTER-DRAIN k VENT WA (5A)
Wilds or Improves thereon,and who contracts for such p(ojects with a
m,Il .cmr(s)Beene.pursuant to the Contractor's License Law. I
BACK FLOW PROTECT.D CE t { FEE SUMMARY
L j I am exempt under Sec. B k P C for this reason
Owner is DRAINS FLOOR ROOD COND. SANITARY .Y N
WORKMAN COMPENSATION DECLARATION RECEIPT pFP(TURF_5-PER SCHOOLTAK Y N
01 hereby affirm that I have o motificate
Insurance
of consent to self-Ineure,ora RECEIPT Y
• certific3800,Lab o(Workeri ComprvaHonlvuranre orarertl(led mpythemaf(See GAS EA SYSTEM AOUTLETS
3800,Lab C.)
Poll p
PARK FR. Y—
N_
CoCany GAS EA:BYSTEM-OVER6(EA) RECEIPT
Certified copy arc leuol. BUILDING
N FEES
Certified copy b filed with the city inspection division. GREASE/INDUSTRL WASTE I FP R PLANCHECK FEE
CERTIFICATE OF IXEMPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY- JOOFT. ,
Uhb section need not be completed lithe permit b forone hundred dollars STORM IiA. Date Recei 1#
($100)Orfy that
- of work WATER HEATER W/VENT/ELCIR ENERGY FEE Y 'N
I rent that emhe ploy
any person in any annex for to become
eemnit b Weed, —
I Whale not employ any person In any manner at m to become eub)M to the WATER SYSTEM/TREATING
Workere'Compenmtlon Genas of Callfomla.Date PAID
z Z Applicant
Z O NOTICE TO APPLICANT:If,after me king thin Certificate of Exemption,you NEW RESIDENTIAL PLMB, SQq. - Date Recet t#
hshould Wcomesubjettothe Workere-Compeneationprovislonsofthe Labor TOTAL:
W Code,you=at forthwith comply with such proboom orthbpM
ersshali be
W
> deemed revoked. BVILDINQ IEE O
tl O - CONSTRUCTION LENDING AGENCY -• SEISMIC PEE
Ihereby affirm that them b a commoction lending agency for the perform TOTAh ELECTRIC FEE
ZO ance of the work for which this permit is Issued(Sec.3097,Civ.C.)
U lenders Name - PLUMBING IEE
LL F Landers Address QTY. t MECHANICAL PERMIT IEE ' MECHANICAL FEB
O W Icertifythmlhave read this applica,lonand nate that the above Information „
C correct.I agresto complywith all etyand county ordinances and mate laws PERMIT ISSUANCE FEES PAID:
>. 01 relating to building construction,and hereby authorise representatives ofthb „
F Z city to enterupon the abovr-men,ioned property for impection purposes. ALTPRORADDTOMECH. Date
V — (WU agree to save,Indemnify an d keep harmiess the City of Cupertino Receipt#
agalostlia tiro,jadgmenb, ands penes which yin anywayaccrur AIR HANDLING UNIT(to 10,000CFM) SUBTOTAL:
Ity covequen gra nme cit permR. AI2 HANDLING UNEP(OVER I0,000CFM) CONSTRUCTION TAX
• Slgnamreof Applicant/C o dor
HAM OUSMATEt1ALSDISCIASURE Date FxluusT Hoop hJiDucn CONSTRUCTION TAX PAID:
pase
WllltheappticanI or(utum building occvpantsmrcorhandlehuardmd HFATINGUMT(TOID(L"11TU) ate Recei t#
material aW daffiond by the Cupertino Municipal Code,Chapter 91Z and the.
Health and Safety Codc dion 25532(a)7 HEATING UNIT(OVER 100,00)BTU) TOTAL;
17-1YenNo
Wllltheappllcans orfumre building occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit ha,anlous air contaminants as defined by the Bay Area Air PAID Qu BtyMan,gc.odDlmdct7 B ILFR-COMPOHPOR100,0(UBTLfi P A I D
❑ Y" n❑No VAN 0.'
16
]have read the hazardousmaterials requirements underChapter6,95 of BOILER-COME(OVER 100,000 BTU)'
the California Health k Safety Code,Sections 25505,25533 and 25534.'l 1992
understand that if the building docs nos currently have a tenant,that It is my NEW RESIDENTIAL MECTL J
SQ.FT.
responsibility to notify the occupant of she requirementa which most be met
prior to Issuance of a Certificate of 0ccepancy.
`
^ CIT Y UI' LUI"Ch I IN( /
Owner or au,horcud agent - Date ISSUED BY-
OILI, FFICE
L: :1�—jam%'�
OFFICE COPY