23558 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMMTNO..
Building Address: 23558
4gM:1 L E I�oti C ^3 r 8
one: APPLICA IIUN hUBMI I IALA Ih
41A1J t,K S,�—UIgfz CITY OF CUPERTINO-BUILDING DIVISION �^
cmc vRmr'a Name: Lic.Nm APPLICATION / PERMIT
Architect/Engi=� Lie.No: BULDINGE.FCTRICAL-PL GMECHANTCAL CATEGORY CO.
QTY ELECTRI ERMIT FEE BUILDING PERMIT INFO
Address: I(� L)IEEW PERMITISSUANC ` 1-1 1:1 ❑
LICENSED CONTRACTOR'S DECLAKAT N
I hereby affirm that l am licensed under provisions of Chapter 9(comment. APPIIANC DENTIAL JOB DESCRIPTION
ingwithsi<full forcea dofsion3 olthe Buslnessand Pro/emlonaCode,and my - �^
license is in fou force and ic.t PLI ANk7.$ I /� �7
Date Class Contr �/ L!/`V
Date GOmtrdROr -
ARCHITECTS DECLARATION 201IXW0AMPS
rc0 7 l understand my plans shallbe used as public records. - 1000 SQ.PT.FLOOR AREA $/SQ.FT.
OIGNSELECTRI L
Licensed Professloal
5 G w OWNER-BUILDER DECLARATION
{-n ♦=d SI'ECIALCIRCUI 715
s., Ihercbyaffirm
that lam31.5,Bfrom
ess a Contractor's License hw for t he
'Z O—-° fo0oaving reason.(SccMon 70315,liminess and Professions Code:Any city or
O Z.F- TEMP.MECER OR INSf.
Cmg� countywhirh requbeas permbe,also rquireatheaprovantfor lah,orrepai _
anystructure paorto Its Lemance,aho requlrcathe applicant for suchpcenott Y ��
I V file a signed statement that he is licensed pursuant to the provisions of the POWER DEVICES' �' I
O w Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi -
3 In s 11GjIVDCEbFCIRIc . j
O thesiobasis for
the alleged exemption.CodeAny)viothat lation f Seem therefrom an VALUATION
f. S9 S the basis for the alleged exemption. Any violation of Section 7031S by an C ETSSWITCHES• r I 00 t
<� appliantfora permit subjects the applicant toa civil penalty of no moretlu
c,o. five hundred dollars($50Q). 1 i
I,as owner of the STORIES TYPE CONSTRUCTION
property,or my employees with wages there sole
compensation,70 Business
ess and rk.xfosdo and structureode:Th not intended or License
La
$ ❑ d fm a—
sale(Sec.apply
to ainow and Profession Code:The Contractors License Law `r-
�$Q
whdoeo
such torn owner of p operyrough who Wilds own employees,
improves
ovide rcory and OCC.GROUP RIS.UMTS
whoovementsa not
dedorough his ownemp,herweprovidedthatsuch
improvements Intendneyearfcoedplelo.tLh mer- tRderwilln cue TOTAL: - -
improvement usold wilhinoneyearofcompleBon,theowner-bullderwlllhave -
OI elenof proving that he did not build or improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE
LL as owner of the ro FLOOD]Dh'E APN
p petty,am exclusively contracting with licensed PERMIT ISSUANCE
contractors constructtheLaw does
nor appy Busmen and of propertfessionay
Coate:
The Contractors License Law does not apply to an owner o/property who ALTER DRAIN k VENT WATER ffN .
Wilds t r Improves thereon, and who contracts for such plajects with a FEE SUMMARY-
[7]
UMMARY- "
c t]1 am,exempt
pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
❑lam empt oder Sec B &P C for thio reason
OLITSIDEFEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner ea Date A J 1 RECEIPT
WOR Kh AN COMPENSATION DECnsent t11'' N FIXTURES.PER TRAP SCHOOLTAX Y N_
❑I hereby affirm that 1 have a certiRate of consent to self-Insure,on
RECEIPT X
mrtifinte of Workers'Compensation Insurance or a certified copy thereof(Sec. GAS EA.SYSTEM-1 INCAOUTLETS PARK FEE Y N
3800,Lab C.) AEC IPTPolicyX
CffX GAS EA.SYSTEM-0VER 4(EA)
Com any BUILDING DI VISION FEES
MCedifled copy is herebyfurnished.the city CREASE/INDUSTAL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified mpybflled with the tllylrepectlon division. '
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAPQ
COMPENSATION INSURANCE PAID / _
(fhissection need not becompleted iftheperout isforons hundmddollar SEWER-SAMTARY-STORM EA.XpFT. Date Reoei t71
($100)nrleae.) WATER HEATER W/VENT/ELFLIR ENERGY FEE Y N
I mrtifythat In the performance of the work forwhlch this permit is Issued,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING Workers av
Compensation Lawnfutomii. Dae - PAID
QZ' Applicant NEW RESIDENTIAL PLMB. SQ.FT. ,Date Remi tN
Z O NOTICE TO APPLICANT:H,after making this Certificate of Exemption,you
Hshould become subject to the Workers'Compensation provisions ofthe Labor TOTAL:
N Code,you must forthwith comply with such provisions orthls permit shall be
LU > deemed revoked. BUILDING FEE
d c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hembyaffirmthat them a construction lending agency for the perform TOTAL: ELECTRIC FEE
Z once afthe work for which this permit is Issued(Sec.3W7,Civ.C.) '
O O lender's Name - - PLUMBING FEE
IL r Lender's Address QTY. MECHANICAL PERMIT • FEE MECHANICAL FEE
(certify thatl have read thiaappliation and aatethat theaboveinformation
O W
C is correct.l agree to complywith all city and county ordinances and orate laws PERMITISSUANCE FEES PAID:
>. relating tobullding construction,and hereby authorize representatives ofthis
F. N city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH.
Z (We)agree to save,Indemnify and keep harmlaas the Clty of Cupertino. Date Receipt#
V against liabilities,judgments,cents and expenses which may in anywayaccrue ARHANI)LING UNIT(TO 10,"CFM) SUBTOTAL:
agalrul said City i consequenceof the grnting of this permit.
AR xANDUNc uNrr(ovFxlp,mpcpM) CONSTRUCTION TAX
V
Signature of Appli t/ ontractor Data EXfiAUS'THOOD(W/DUC'D CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a pplica nt orfutum building occupant store or hand le hatardous HEATING UNIT(TO I OILODO BTU) Date
material as defined by the Cupertino Municipal Code,Chapter 9.1;and the
Health and Safety Code Section 25532(a)I HEATING UNIT(OVER 100,000 BTU)
❑Yes r]No
- -- Willthe appllaot or future building oem pant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havrdoua air rontamlmnts as dented by the Bay Area Air n p I D
Quality Management DisWctP BOILER-COMP 100,0M`OR l00,VBTU) T M .
Yrs ❑❑No
hove mad the haurdOuamaterials requlrcmentsunder Cha pte4.I of BOILER-COMP(OVER 1N,OW BTU)
the Gltandtatlith ASafety Code,SMlomntly have
a tenant,
that.1 IIss'� 4 1992
understandthatnotify wilding dont of the currently thatb is my NEW RESIDENTIAL MECH. SQ.FT. JUtal
- responsibility to notify the pant of the requirements whichmust he met t '
prior to issua cola rtificato of rmpancy.
P` t z �� CITY Ur- 'vUr'r.ni uvV
1Owner oM'�� by `.
O.vneroriuth5rlud agent Dae ISSUGDBY:
TOTAL:
OFFICE COPY