23593 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulldin Noted Identification PERMIT NO.
Building Addreaa;MITh I
awr - 23593
ser.
° CITY OF CUPERTINO-BUILDING DIVISION `
C°ntr=dor'c Lic No APPLICATION /PERMIT Z��Z
T l— _S� BUILDINGaFiCTRICALML RING-MYLH MCAL CATEGORY CONTROL# '
�ArcMtett/En neer. Lk.Nex ,
-. 1- -- ,• t-u - - ".LTTEtttt 1. .BUILDINGTERMIT INFO' 7
5 s C� n / QTY ELECTRIC PERM1T ` i
Address: S !�' cJrv/ PER,WTISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby aff1mr,lut l am Uro
cenaed under pvhfC
lonsohapter9m
(comen APPLIANCESRESTDENf1AL JOB DESCRIPTION
Ingwith Sectbn7000)of Divislon3p(the Bualnsaandl'rcfndons Code,and my
license la In full fo d d(ect. ,l PANELS �O�• .
Limn-` CHI I N ,
Date Contractor
.I ARCHITECTS DECLA ATO ' 301'101 PSP
1Q�0ZpC ]unde.tand plans shall be ypublicre s. O 1 SQ.Pal'.I7.00^RAREA S/SQ.FT.
E�()
Licensed P m 1, 4,K'
'� SI SL CAL �1 II b� ,® 1_
LG�I OWNER-BUILDER DECLARATION ` GM M uuuililil iI1S�� E
71., 7 Ihereby afBrmthat I am exempt fromthe Contractor'sLlcense Lawforthe `�• 1 �n n
qqqq following reason,(Be tlon 7031.5,Business and Prefesslons Code:Any city or / DIA Ij— E F1
�Rf
gig ` county which requirma permit to construct,alter,improve,demolish,ormpair T� E IIt L 1 T.
7 anyswctum pct°rt°Its laseance,alsorequlm theappUant forsuch permh to POWER DEVs B
4,'a file a signed statement that he b Ilrensed pursuant to the prevlaloru of the 1 DA E '
3O� Contractor's License Law(Chapter 9(commencleg with Section 7000)of Dial- SWIMMING POO E C /"
(- << al..3-fthx B.atr..xnd Pmesslmu Code).,that he Vexempttherefromand VALUATION
�'s the bash for the alleged exemption. Any vlolatbn of Section 7a)L5 by any 1 O O�
<$'
applicant fora permit subjects theapplicant to a dull ami of not rrorethan OUTLETSSWITC •)TURES 11
app pe jeFamily
flue I,as o nerdolof the pr). NEW RESIDENTIA ELECTR_SQ FT.MI,as owner afthe property,or my employes with wage as their Bole 510RIE5 TYPE CONSTRUCTION
compensation,wllldothe work,andthestructure h not Intended or offered for
O sale(Sec,7074,Business and Pnefesslm s Code:The Cont.etols Llcenie Law
does not apply to an owner of property who builds or Improves therein,and OCC.CROUP RES.UNITS
who doessuch work himself or through his..employe.,provided that such
Improvementsare not intended proffered for sale.If,howeverthe building or '
Improvement 6udd within oneyearofcompletion,theowner-bu Iderwlll have
th�rdenof proving that he did not build orlmprove for purposoofsale.7. QTY, PLUMB[NCPERMIT', .':XEE, FLOOD)ANE APN
I,as owner of the property,am exclusively contracting with licensed pFRMIT ISSUANCE '
contractore to construct the project(Sec,7074,Business and Profenlore Code:
_ The Contractor's License Law does net apply to an owner of property who ALTER-DRAIN&VEM-WATER
builds or Improves thereon, and who contracts for such projem with a (EAI
mjl[Iador(s)Ilcensed pursuant to the Contractor's License law. .� �:,,FEE SUMMARY' '4
I am exempt under Sea B&P C for this reason BACK FLOW PROTECT.DEVICE
Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner
WORKMAN COMPENSATION DEC"RATION RECEIPT#bT%TURPS PER TRAP SCHOOL TAX Y N
1 hereby affirm that I have a certificate of consent to self-Insure,ora RECEIPT
N
I of Workers'Compensation Insurance or a.1ifled copy thereof(5ec. CAS FA.SYSTEM-1 INC.40UTLETS .�► PARK FEE Y N
3800,1.6 C.7
Policy# — RECEIPT N
Co ny GAS EA.SYSTEM-OVER 4(P) BUILDING DIVISION FEES
femRed copy Is hereby filed
the cid. GREASE/INDUSTRL WASTE INTERCEPTOR PLANC ECK FEE
. s�ICertlBed copy Vflied with the city inspection divielon. � � {O
////'''����''' CERTIFICATE OF FXEMPFION FROM WORKERS' I CREASE TRAP PAIp� O /"{ S1
'COMPENSATION INSURANCE SEWER-SANTTARY-STORM FA.30OFT. Date `/Re—t#
(fhlasese.) need not be complded If the permit Vfororu hundred dolls.
(51I mnify that
`ed, WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I ll net employ
any person
In any manner for to become
a sub is Ito the —
I shall not employ any person In any manner ro u to become subject to the
Workers'Compensalion Laws of Calif meals. WATER SYSTEM/TREATIN'G
la. Date PAID
'O Z Appllomt
Z Q N0710ETO APPLICANT:[t,aher making this Certlfloate o(Exemptlon,you NEW RESIDENTIAL PLMB. SQ.Fr. Date Recei t#
Hshould becomesubjxt to the Workem''CompmuatlonpmWl°v°f lne labor TOTAL:
N Code,you most forthwith comply with such pruvialoro or this Permit shall be
deeed revoked. B
W
mc CONSTRUCTION LENDING AGENCY SEISMIC FEE Q
I herebyafOrm that there b a construction lending agency for the perform TOT ECTRIC FEE
EL
O once of the work for which this permit b Issued(Sec.3097,Civ.C.) -
V Lender''N'r"C PLUMBING FEE
1L F Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Imdlfythatlhavereadthuappliutlonan matethattheabovelnformation
M 6cormet Iagree to comply with all city and county ordinances and state lawsPO(MIT ISSUANCEFEES PAID:
N relating to building construction,and hereby authpdu representatives of this
HZ city to enter upon the.1xaemcntio"ed property for inspection purposes. ALI£RORADDTOMDCH.
an d keep harmless the City of Cupertino Date Receipt#
.
nave,Indemnify
against Iityincon ofnd expensetof th cosy Inanywayaceme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
againstu City in con of the gran0n which permit -
�� �9 AIRHANDLI C UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Si tureof Appll cntractor —!� EXHAUST HOOD(W/DUCp CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant atom or handle huardous HEATING UMT(TO 100,000 BTU) Date
material as dcMedb the Cupertino Municl al Code,Cha ter 9.] Reeel t
y pe p p 3,and the
Health and Safety Cole Section 25533(a)7 HEATING UNIT(OVER 100,000 BTU) TO
❑ Yea NN.
Will the applicant orfuture building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air cpntaMnanb as defined by the Uay Arca Alr
Quality Management District? BOILER-COMP OHP OR 100,000 BTU)
❑Yes ONo pp ^
Iheve read the haurdous materials requirements under Chapter 6.95 of BOILER-COMP(OVEi I W,000 BTU) r 1 ~
the Glifornla Health&Safety Code,Sections 35505,25533 and 25534. I
understand that if the building does not currently have a tenant,that it In my NEW RESIDENTIAL MECH, SQ.FL MAY 20 19
responsibility to notify the occupant of the requirements which=at be met
prior to laua nee of a Certifi ate of Ocen pa ncy.
Owner or authorized agent Date ^_ ISSUED BY!`II'#C-s
OFFICE COPY