23926 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - - PERMIT NO.,
BuBding Address: : . 2,3926
g v D1
wears ante:( hone: ApPLicATrMTMN7TTrX7r7TE
( ,Vt38 2 CITYOFCUPERTINO-BUILDING DIVISION '
Contractor's Name: y Lc.Nn: APPLICATION / PERMIT (�
a ^1 y W 'M �LldYO BUILDING-ELECTIiICAI PLUMBING-MECHANICAL CATEGORY CONTROL p
Arele ted/Engineer. Lie-.No:
- dTY'•t. t ;ELBCTRICPFRMJT : FEE • 'IlUjLRING•PERMIT INFO
Address: PERFIITISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Iherebyaffirm Hut Tamllcencefthe Bu nessaonao(Cssims9de,and e- APPLIANCESRESIDENTfAl JOB DESC
inense Is In fon force a(Dlvlelon3otthe Buslneesand ProfeasionsCode,and my
' license is in luB tore and effect. ,. PANELS
License Class Lie.If \ 1
Date Contractor12 IQ 209 ANTS
ARCHITECPS DECLARATION 201-1000 AMPS
�qqtuu OaX I understand myplatashag be used as publicrecords. OVERIOOOAMPS SQ.FT.FLOOR AREA $/SQ.FT.
E o�j Licensed Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION - h
�., Thereby affirm that l am exempt the Contractor's License Law
for the SI'ECIALCRtC T/ n 1
Zp following reason,(Section 7031.5,Business and Professions Code:Any dty or a
TEMP.METERRPO EINST. ,
erg cmntywhichrequiresapev ttommtmo,alteglmpmve,LemlWh,ormpalr _
g 'anystrudure pectin its issuance,also requfresthe applicantforsuch permit to 1 V u �
t5 O file a signed statement that he is licensed pursuant to the provisions of the POWER DEVICE
Q6 O Contravmr's License Law(Chapter9(commencingwith Section 7000)of Divi- gyyfM,YgNG LELECT
sion3o(the Bualnessand ProfesslmuCode)mthat he la exerepttherefromand VALUATION
< 'the bash for the alleged exemption. Any violation of Section 7MIS by any OUTLETS-SWIF.Ba FTXTDREg--- 6
DO applicant fora permit subjects the applicant to a dvil penalty of not more than
five, as owner of
(epm NEW RESIDENTIAL ELECIR SQ.FT. STORIES TYPE CONSTRUCTION
.❑I,as owner of the property,or my employees with wager r offered
sole
a mmpenea 70K Busthe h,
Psfesdo s Codureh not Ntended License Law
sale(Sec.apply
to ainow end f Property
Code:The or improves
License Law
whododoes tapply torn owner o(p rough whatr,ilds empoy.,pr rated eon,and
that
OCC.GROUP RES.UNITS
who doeasuch work himself or through hlsown employees,provided that such
Improvements are not Intended orof(ered forests.If,however,thebuilding or TOTAL:
Improvement usoldwithlnoneyearofcomple lorythe mveer-buflderwill have
tIdea of Freeing that he did not build or Improve for purpose o(sale.). QTY; •.:t�' '.PE-UMBING'PERMIT 'TFEE'. FLOOD ZONE
tyAPN
L ae owner of the property,am exclusively contracting with licensed ' PERMIT ISSUANCE
contractor to construct the project(Sec.7044,Business and Professlona Code:
The Contractor's License Law does not apply to an owner of property who ALTER-0RAIN&VEN7-WATER(EA)
builds or improve thereon,and who contracts for such ptujeds with a `E ,$Ut
cgBtfador(s)licensed pursuant to the Contractor's Limn.Law. BACK FLOWI'ROTECT.DEVICE
EEMMARY'
Ll I am exempt under Sec. B k'P C for this reason
DRAINS-FTOOA ROOF,AREA,COND. SANITARY Y N—
Owner Date RFOE]PTp
WORKMAN COMPENSATION DECLARATION PER TRAP SCHOOLTAX Y— N—
❑I hereby affiorka that I have o Insurance
certificate of consent to opythereo ora RECEIPT st
certificate o(Workern CompemaHonlmurantt ora certi(led copythereo((Sec. GAS FA.SYSTEM-1 INCA OUTLET'S PARK FEE Y N
Polis 38m,lab C.)
Policy If GAS FA SYSTEM- — RECEIPT M
Com any SYSTEM-OVER BUILDING DIVISION FEES
Certified copy le filed hereby
the cityed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certitled copy le filed with the city inspection division.
CERTIFICATE OF E)ITMPTION FROM WORKERS' GRF-ASETRAP' PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 20047 Date Recei t#
(fhfssedbe
ion need not completed if the permit is(Drone hundred dollars
(Sl Icolly that
- WATERHEATERW/VENT/I].ECTR ENERGYFEE' Y N
I ll net employ
the person In annce the mannworker
oar to become
pesubjecmit is bound,othe —
I shag not employ any person in any manner m m to become subject m the
WoCompensation Lowe of California. ATER SYSTEM/T,RFATING
ia.Date - PAID
0 Z Applicant
t
ZO NOTICE TO APPLICANT.]$a(ter making/his Certificate of Exemption,you NEW RISIDENTIAL PCMB. SQ.FI', Date Recei t#
Fshould becomesubject to the Workers'Compnsatlon provisions ofthe Labor TOTAL:
CC
W Code,you mu at forthwith comply with such provisions orthls permit shall be BUILDING E
W 9 deemed revoked. _
CL o CONSTRUCTION LENDING AGENCY SEISMIC PEE
I hereby affirm that there lsa comtructfan lending agency for the perform- T ELECTRIC FE
M 0 anoe of the work for which this permit is heated(Sec.3097,Civ.CJ E
U _ Lender's Name PLUMBING FEE
LL - Lender's Address QTY, ,•MECHANIC L PERMIT '':'FEE'•' MECHANICAL FEE
O W ]certitythatl havereadthta appllrationand statethdttheabove in(ormaHo ••
iscorred.I agreeto comply with all city and county ordinances and date laws PERMIT ISSUANCE FEES PAID:
>. (L relating to building comtrodion,and hereby authorize representatives of this -
?W city to enter upon the above-mentioned property for lmpection purposes. - ALTER OR ADD TO MECH.
(We)agree to save,Indemnify an If keep harmless the City of Cu patine Date Receipt#
V against llabllitlee,judgments,costsand expenses which may In anywayacerue AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL;
against said City In consequence of the granting of this permit
AIR HANDLING UNIT(OVER 70,000 CFM) CONSTRUCTION TAX
- 2-
Signatureo! ppllcant/Contract r Date EXHAfTST HoOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIA )ISCLOSURE
Willthe applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,WO BTU) Date .RCC ' t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I lealth and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU)
❑ Yes MN. � � TOT �7
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE REBID) I$$GlANCE DATE
which cunt havrdousair contaminants as defined by the Bay Area Air1"'
Quality Management DlsMd7 POR 10g0(VRTU) I D -
4 Yes No ���
havcread Health
car materials undernd 2554.1 of BOILER-COMP, 100,000 BTU)
the understand
to I lealth buildinghe Safety Code,Section 25505,ve a t and,that I Ignats_
uxPOnsindthatn tifytheoccupant not errently e4uhurentsw which
that it metL MECH. SQ.FT /x7`VaGJrespomlbsity tonce of aCertiicte of o/ pancy.irementawhich must be metyITp�Fprior to issuance ofaCertificate o(Occvpanq.Own or authorized agent - Dce - ISSUED BY:.
.TOTAL:
OFFICE COPY