23570 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification PERMIT NO.
11.00Jng Address: 1 _ 2 3 5 7 0
a
w re ams:
t�V) CITY OF CUPERTINO-BUILDING DIVISION
' cn tr ars Name: /y��) Lia.No: APPLICATION I PERMIT
� 4�L37 0 BUILDING-ELECTRICAL-PLUMBING-MECMNICAL CATEGORY CONTROL#
Ar Iced/ glneer. Lk.No;
- QTY ELECTRICPERMIT FEE BUILDING PERMITINFO
Address: PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACT'OR'S DECLARATION
I hereby affimtthat l nn licensed under provisions ofChapter9(commen APPOANCESRIESIDENMI, ]OB DESCM-HON
ingwith Section 7000)of Divislon3ofthe Busineeeand ProfeWm*Code,and my
PANELS
license le In full fa red d(ect. �� �l •��
"mnyo
C o Llc Y _ 9
Date Contractor
ARCHITECTS DECLARATION 201-1000 AMPS
q�q�uu O I understand my plans shag be used as public records. OVER HIM AMPS SQ.Fr.FLOOR AREA $/SQ.Fr.
Fi Licensed Professional SIGNS ELECTRICAL
«<< OWNER-BUILDBR DECLARATION i
�i SPECIAL CIRCUIT/MISC
I"'Yla owing rafBrmthatlam31.5,B exempt fromthe Contractures Code:
ehy cityfor or
7.p following reason.(Section 7BI1.5,Business and Professions Code:Any city or
r'Z t-.a TEMP.MEITR OR POLE INST.
,a ..t countywhlch rcquiresa pertNt to mrutrucL alter,4nprwe,demolbh,or repair
.0 anystructure prior to Its ivsuance,al,omqubestheapplium for such permit to OWER DEVICES
c. file a signed statement that he Is licensed pursuant to the provisions of the .
Oct Comeector's License Law(Chapter 9(commencing with Section 7000)ofDivi.H�OS
do,3ofth.BusinessandProfemlo®Code)orthatheisexemptlhcmfromand SWIs(MINGPOOLEL[C[RIC VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any
7y,�jj!�g�g��6i appRcantfor.permit subjects the applicant too civil penalty a not morcthan OUILETSSWITCHFSHXTURES �DO t
Ejy five hums ed owner of theprj. NEW RESIDENTIAL ELECTR__SQ.FT. STORIES TYPECONSTRUCTION
5 2 6 ❑f,as owner of the property,d my employees is with wage as thele dole
compensation,will B..( Ramo Profdthestructure Vnot intended or offered for
❑ sale(Sec.apply
to alnow and f property Code:The Contractors Lleerue Law
does naapplytoan owner o(p rough who Wlmor Improves y.,provided t oRardw1mclOCC.GROUP RES.UNITS
0.0. impro s eutamntInten or through hie own employ., at such
Improvementserenot Intended earofco pletio.ILhowever, elder ill have
TOTAL:
Improvement bwW withinonlyearofcompldion,theowner-buBderwlll have
ttiLturden of proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
Lf I,as owner of the property,am exclusively contracting with licensed PERMITL'ST)ANCE
rontncton to construct the pmjrd(Sec.7016,Business and Professions Code:
The Contndor's License Law does not apply to an owner a property who ALTER-DRAIN h VENT-WATER(EA)
Wild. or Improves thereon,and who contracts for such ptojeda with a
cgp{pdW.)licensed pursuant to the Contractors Llrense Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LII are exempt under&c. B k P C for this rcuon
DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y N
nljTqIDF FEES
Owner Date RECEIxI'N
WOim that COMPENSATION DECLARATION FDnURFS PER TRAP SCHOOL FAX Y N
❑I hereby afforke that I have o lmurate of consent to pythmre,ora RECEIPT N
3800conif1 ale°fWorken'Comperieatlon lmuuranre ora rerti(Ied copy/hamo((Sec' GAS EA SYSTEMI INCA OUTLETS PARK FEE Y N
300Q his Cd
Policy# - RECEIPT M
Cam a GAS EA.SYSTFM-OVERd(EA)
Y BUILDING DIVISION FEES
Certified copy b herebyFamished.thehed. GREASIPANDUSMI,WASTE INTERCEPTOR PLANCHECK FEE
❑
Certified copy V filed with the city inspection division.
CERTIFICATE.OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 20011' Date Recei t#
(Thlssedlen need mat be completed If the permit V forom hundred dollen
($1 I10)orlese) WATER HEATER W/VENT./ELECTR ENERGYFEE Y N
Irertlfy Nperformance
et In theo(thework f°rwhlch this parodic Is Weed,
I shall not employ any person In any manner so as b ofte ed to the WATERSYSTEM/,TREATING
Workers'Cprypenestme La fCa lfoms,t11ateX.urd PAID
O NOTApplICE s�1-� Y„ JI NEW RESIDENTIAL PLMB.__SQFf. Date Recei ted
Z z NOnCoT� MLlLeetl�f:�a�r makingthle Certltkate ofF emplion,you
Fshouldbecomesubjed to the Worked Compmadkr Provisions°(the Labor TOTAL:
a. N Cie,you moat feet lhromply MthduehproWimaorthbpemdtahallbe
> B I G
deemed revoked.
ed.
ION LENDING AGENCY SEISMIC FEE t
1 hereby afRrm that there is a construction lending agency forthe perform TOTAL;
ELECTRIC FGE
D 0 arm of the work for which this permit is issued(sec.3097,Cie.C.)
L) Lend era Nam PLUMBING FEE
LL H Lender.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Imdlfylhatl have read thlsappliatlonend Hatethaltheebove information
Iscorred.I agree to complywilh a0 city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
- 1 relating to building coratructlrn,and hereleyauthomeerepementativesmthio
f. 2 citytoerterupon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
(We)agree to save,Indemnify an d keep harmless the City o(Ceperth o Dale Recel tic
V againsth.bilitles,rydgments,covaand expenses which may In any wayecaue AIR HANDLING UNIT(TO IO,ODO CFM) SUBTOTAL:
ag 1 t old Cityn eon erre of l c gr+ming this perenit.
AIR HANDLING UNIT(OVER 10,0DIICIM) CONSTRUCTION TAX
Slghaffin ofppl�iant/Contnctor Data EXHAUST HOOD(W/DUC) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haaardous HEATING UNIT ITO 100,000 BTU) Date ReCel Ile
material as de0md by the Cupertino Municipal Code,Chapter 9.12,and the -
liealthandSafetyCod ion 25532(1)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes No
Willtheapplicanto futumbulklingoccupant useequipmentordevims VEMTLATION17AN(SINGLE RESID) ISSUANCgILTE
which emit havamdrusalrcontamkantsasdeMed bythe Bay Area Air u aY
Quality Management u d? BOILER-COMP PIE'OR 100,DM BTU)
4.veN° APR 24 Y
read clash struteriala requirements under Chapter 6.95 of BOILER-COMP tOJ,000 BTU) 1(1[1ay
the California Health A Safety Coda Sections 255D5,25533 and 25534.I 1s7JG
understand that if the building does not currently have a tenant,that It 0 my NEW RESIDENTIAL MECH. SQ.Ff. !��
maporalbilitiny to rally the occupant of the recta menta which must be met Cll r'ur VWrCf11 HYV
pto iwua eofi Cert a[eo Occup. cy,
Z
11Q,aul odud.gen - ISSUED BY: V CC
TOTAL:
OFFICE COPY
,
74�
�ZX 4 ''
APPROVED
�r ACCORDANCE WITH THE CITY 0
ERTINO CODES AND ORDINANCES
DATE`
SIGNED_ �0
This set of plans and specifications�—MUC
be kept on the job at all times and it is un
lawful to make any changes or alleraticn'. 'n�
on same without. w itton peMssion trcm u U APR Z 1992
the building Dept., City of and
specification!
/' ���
The stamping of this pian and speclhcalion! `�
SHALL NOT be head to permit or to be or, BLDG. INSPECTION DEPARTKED
approval of the violation of any prc isin r CIN OF. CUPERTINQ
it any City Oidinance or State
Yant M astc�i✓r,a�
v
•CIT
e /10
z57OFFICE COPY
L"'`b tar
60
�jk � 1 �t ��stall atio �
cZ> z 4 X 32" ou�� ao y
OW �1er ; Go�,tractar -. N�aS�eYGra�'t
�a v�-C 1�o box u} I5
C om° q4 .