23450 APPLICANT TO FILL IN INFORMATION WITHIN REP LINES — USE BALL POINT PEN ONLY
Building n - - - - PEHMITN2'3 4 5 0'
BuildingAddress; -
s ams: one. p
ikp?ner 7t.�� CITY OF CUPERTINO-BUILDING DIVISION
^ ad.raNana: Lic.No - APPLICATION I PERMIT
b3n8lGas BUILDING-ELECTMCAI PLUMBINGMECHAMCAL .. CATEGORY CO
ArcMkd/Engineer:. ' Lk.Na kk
I�y 'ELECTA`<T,..-PpRY'vt ht,) .I FE$ l t '. �BUItiPING YERMITINFO ii -
naareasJC L10� L„p\� .•• PERMITISSUANCE''• 1:1 ❑(, .
LICENSED CONTRACTOR'S DECLARATION
.I hereby aHtrm that l am licensed under provisions of Chapter 9(comment, APPLIANCES-RESID L - JOB DESCRIPTION
It... irfon7000)o(d off on3.HheBuslneswnd Pro(esslonsC,.ode,and my ��
]cense b in fun f and dfed., � PANELS - bi 1, `
License g Lk.p 34 a I Ip3 w
Date Contractor VP axw1 ,
ARCHITECTS DECLARATION
9O O I understand my plana shall be used as public recoMe. I00 SQ.FC.FLOOR AREA. $/SQ.FT.
�j Licensed Professfoul ; .SIGNS CAL
In I FLr`7� OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC. „
zl.., •-6 thereby affirtnthit l amexempt from the Contradore Lim..Law for the
oo following reason.(Section 70115,Business and Professions Code:Any city.,
OZs'u9 TEMP METER ORPOLE]NSC.
county which requimmid
a perttumnstru ,alter,Improv,demolish,
q`•E ,iei arystrudurepriortoit.s.0 nce,alsorequirestheappllcantforsuchperMtto
Q 3 Elle a'9lgned statement that he it licensed pursuant to the provisions of the POWER DEVICES
Ow 'COntrado,al.kerse Law(Chapter9(mmmeneingwith Section 7")of Divi- SWIMMING POOL ELECTRIC
O Acn3Ofthe Business and Pmfeglms Code.,that he isexempt therefromand - A VALUATI N
the basis for the alleged exemption. Any violation of Section 70315 by any
0 applicant fora permit subjects the applicant to a civil penalty more more than OUTLETS-SWITCHES-F1 '
QQq five hundred dollars(g5DO). NEW RESIDENTIAL ELECTR'
0I,as owner of the property,or my employees with wages as their sole STORIES TYPE CONSTRUCTION
rompensation,wllldothe work and thestrudure Is not Intended or offered for
-In(Sec.7044,Business and Profegbv Code:The Corsham.,'.License Law
r�$ does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RES UNITS
who does suchwork himself orthrough his own employees,provided that such
improvement Rare notproveintended oroffered for sale.IThoweveythebullainger
impmvementbsold Mthinoneyearo(completion,theowner-buBderwlllhave
rite urden of proving that he did not build or improve for purpose of gle.). QTy;'.'t;`1, .�t , -FLOOD ZONE APN
uu L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE' -
contractors to ronstrod the project(Sec.7044,Business and Professions Cade: I
-
The Contmetor's License Law does net apply to an owner of property who ALTER-DRAIN kVENT-WATER(EA)
Wilds or Improves thereon,and who contracts for Ruch projects with e
cgR�[ador(n)licensed pursuant to the Contractors EE';$UMM
License Law. BACK FLOW PROTECT.DEVICE �;n`. tx 1 ,F, A$Y. •i''^
LJ I am exempt under SmB k P C,f°i this reason
ner, DRAINS FLOOR ROOF,ARRA,COND. SANITARY Y N— -
Date _ _ RECD.#
❑ �WWORKMAN COMPENSATION DECLARATION FIX .i.�yi ^ (Iww OOL TA% Y N_ ,
I here affirm that I have a certificate of consent to self-Insure,ora T1 lel ` 'I f RFRm't.#
certificate ofWOrkeg'Compersatlon Laurance.,a cenffiied copythereof(Sec. GAS EA. $_TEM-I INC.40UILE1'5,7� P FEE Y N
3800,Gb CJJ
Poli,#1 i'1[� l 359 •' P � RECEIPT#
Co an - G EA. TCM-OVER4(EA)
Y�I A - i BUIL DING DIVISION FEES
�cer<Ified copy is hereby furnished.. CR a/INwASTEI P NCHGCK FEE
�I Certified copy is filed with the city Inspection division.
`-Y CERTIFICATE OF EXEMPTION FROM WORKERS' GR TRAPJ,_ _.,,�T 'AID l W
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 20OFT Date Recei t#
Qhis semionneed net completed RtW permit info,one hundred dollars
($100)mftifyss3 ' WATER HEATER W/VENT/ELECTH ENERGY FEE' Y N
]certify that In the performance Pa..inan the numner Was to become
permit Issubjec lowed,
I shall not employ any person in any manner at as to become wbjed to the
Workers'Compensallon Laws of California. Data WATER SYSTEM/TREATING ' PAID
Z'Z . NOTICE[ - NEW RESIDENTIAL PLMB._SQ.Fr. Date ReL•ei t#
ZO NOTICEco MPLICANT:e orloonakingthis Certlflrateo(Exemption,you
should become subject t the W.rkert Cuch provisions
provisionsofthe Lab or TOTAL:
~ > deemedyou ml,at ed. hwlehcomply with such provisions orchis permit shall be - BUILDING� � deemed revoked. � _� •
a CONSTRUCTION LENDING AGENCY ` SEISMIC FEE CD
Iherebya((irmthat there u a ronstrodion lending agency(or the perform TOTAL: ELECTRICFEE
Z anaofthework((o`�which tFls permit bLgued(sec.3097,Civ.C.) '
U O lenders Name_Itil1Al - i - PLUMBINGFEE
14, H Lenders Athatl QTY MECHANICgL,PEI{111 T 3, ;FEE+;i' MECHANICAL FEE
O W Icedr(ythat]have readthbappllesllonand statethatthe aboveinformation
lamried.I agree to comply withaB egyand mortyordinances and state laws PERMITISSUANCE FEE-PAID-
-
to
relating to building ronstmetion,and hereby authorize representatives ofthis
F N city to enter upon the above-mentioned property for lrspeetion purposes. ALTER OR ADD TO MECH. -
? (We)agree to save,Indemnify an d keep harmiess the City of Cupertino Date Recei t#
V against liabilities,judgments,cogs and expenses which may In anywayaccme MR HANDLING UNIT(to 10,000 CFM) SUBTOTAL•
against City In n u of the granting of this permit.
3 AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Slgnature.(Applkant/Contra Or Date EKHAUST HOOD(W/DUCT)- CONSTRUCTION TAX PAID:
HAZARDO MATERIALSDISCLOSURE -
WilltheapplicantOrfuture Iliing omupantstore or handle hazardous ]HEATING UNIT(TO 100,000 BTU) Date • RCCOI t#
material as defined by the Cupertino Municipal Code,Chapter 9,17,and the
health and Safety Cadp,Sedkn 25537(a)7 HEATING UNIT(OVER 100,0W BTU) TOTA '
FI Yes CKN. .
Will the applicant d&7 re building ocmpantuse equipment ordevices VENTILATION FAN(SINGLE RESID) 'ISSUANCE DATE
which dot hazardous air contaminants as defined by the Bay Area Air - n
alityManagement istrid7 BOILER-COMP QHP OR 100,OM BTU) P A Ir®
Yue No
have read thehaz us materials requirements under Chapter 6.95 of- BOILER-COMP(OVER 100,000 BTU)
•the California Health k Safety Code,Sedima 75505,25533 and 75534.'1 ����
understand that if the building does not mriently have a tenant,that It is my NEW RESIDENTIAL MECH: SQ.FT. �AR 2 6
onporsi ilaytonolilytheo pant°(the requirements which must be and /s
prior t° uance Ce i i teof Occupancy. CITY U1, (y(/C'CTII INU
.Owner Or au(horizcd agent e - ISSUGDB
TOTAL:' rr
OFFICE COPY