23841 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
rBundln Project Identification PERMITNO.
Buildingia,: �l y�t1 C7' 23841
I 1
nen Q�/ pone: O AL DA
!.4 Prlcsa ( /�J'60JrO CITY OF CUPERTINO-BUILDING DIVISION
eq�r ao' Name: n �r.►'pyo APPLICATION I PERMIT ` Zi
Architect/ er. Y BUILDINC-MMTRICALPLUMBINC-MFOHANICAL CATEGORY CONTROL
Lie No:
y ( `,N QTY • ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: r/ ,^/ V SI r� PERNI TISSUANCE ,,,. ❑ .to ❑
LICENSED CONTRACTOR'S DECLARATION
Ihth bdifirmtlutlam Bw3ofhe Busi essanssof Chap[er9(commrnc AI'PIlANCISRES[DENTfAL JOB DESCRR'TION
licumeh Sectlon 7000)of d diedn3ofthe BuslneeaandPro(essionsCade,and my
license k In -to d effect. _ PANELS rr.
Llcen Cl
Date Contractor TIII(_'
AACHITECPSDECLARA31 rd DO AMPS
Tow reO ZpC I understand my plans shall be used v public records OVEROVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
E (3 Licensed Professional SIGNS ELECTRICAL
«< LL7
OWNER-BOLDER DECLARATION SPECIAL CIRCUIT/1119CZ � l herebyaffirm that l am exempt from the Contractors Llttnse Gwlor the
o following reason,(Section 7031.5,Business and Professions Code:Any city or
pty countywhich requlresa permktocmutruct,alter,improve,demolish,orrepair TEMP,METER ORPOLE INST.
.7 anystruaure priorwits issuance,also mqulnrethe appilcamforsuch perMtto O POWER DEVICES G ,file a signed statement that he Is licensed-pursuant to the provisions of the �i7/4 3
ContractorsLkr..GwfChapter9(mmmencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
.1137 slon3 ofthe Business and Pmfemiom Code)ortha he i,exempt therefromand VALUATION
the bask for the alleged exemption. Any violation of Section 7031.5 by any
4X applicant/ora permit subjectsthe applicant to a civil penalty of not excrethan OUTLETSSW(TC[iESFIXT[1RE5
five hundred dollars($500). NEW RESIDENTIAL ELECTR
❑I,as owner of the property,or my employe"with wages a,their sok SQFL STORIES TYPE CONSTRUCTION
compensation,will clothe work and thesbucture Is not intended or offered for
O Bale(Sec.7044,Business and Professions Code:The Contractors License Law
does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RFS.UNITS
0.0. who d^essuch work himself or through hisown employees,provided that such
Improvements are not Intended or offered for ask.If,however,the building or TOTAL:
Improvement k sold within oneyearof completion,the owner-budderwllt have
tlden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
M as owner of the property,am exclusively contracting with licensed PERMITISSUANCE
contractors to conatroct the project(Sec.7614,Business and Professions Code:
The Contractor's License Lw does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
build, or Improves thereon, contracts and who contfor such p -
6ojects with a FEE SUMMARY
cgR¢aco 9)licensed pursuant to the Contractor's License Law. BAIX FLOW PROTECT.DEVICE
L.I I am exempt under Sec. B k P C for this reason
Prrc
Owner DRAINS.FLOOR,ROOF,AREA,COND. SANITARY Y_RECEIVE N Date #
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOL TAX Y_ N_
con hereby orkers that I have o imus ra c of consent to op(tessurethem!or ��.F#
cert lcate ofWorkers'Co1m1pematlonlnsuranmwarentifled copy them!(Sec.
3800, GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
11 `4' RECEIVE#
PPolicy## - GAS-EA.SYSTEMAVER 4(EA)
Compact ��tn, BUILDING DIVISION FEES
❑ III(ierionpy is hereby furelshed. �— cl:ensE/[NDUBIRL WASTE lnreRCEPTOR PLANCHECK FEE
-rofled copy k filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANTTARYSTORM EA 2DOPT Date Recei t#
(Thos section need not be completed lithe permit k(Drone hundred dollars
($100) as6 WATER TREATER W/VENT/ELECTR ENERGYFEE Y N_
]certifynfifythat the performance of[he work for which this permit Is Issued,suetl,
I shall not employ any person In any wanner so a,to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of Catofo nla.Date PAID
O Z Applicant Date Recei [#
Z O NOTICE TO APPLICANT:If,after making this Ceni(Icate of Exemption,you Nh-W RESIDENTIAL PLM B. SQFF.
should become subject to the Workers Compensation provisions of the Labor TOTAL:
Vl
Cods,you=at forthwith comply with such provisions or this permit shall be BUILDING
deemed revoked. FEE
W
G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there k a mretruction lending agency for the perform- ELECTRIC FEE
Z ance of the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL:
V O Lender's Name PLUMBING FEE .
IL — Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OWI.Aitythatlhavereadthkapphrellonand statethaHheabove Info matlon
IL iscomed.l agree to comply with all city and county ordinances andstatelaws PERMIT ISSUANCE FEES PAID:
- W relating to building mmtruction,and hereby authorlae representatives of this
(— Z city to enter upon the abovcmentioned property for inspection purpose,. ALTER ORADD TO MELH. Date - ReCOi t#
_ (We)agree to save,Indemnify an d keep harmless the City of Cupertino P
against liabilities,judgments,ounts.M..penses which may lnanywayaccrue AIR HANDLING UNIT(7O 10,000CFM) SUBTOTAL:
,old Citylncons ancefthe anti g fthie perTit AIRHANDONGUNR(OVER10,0DOCFM) CONSTRUCTION TAX
11 1,411;—
SI re of Applicant/Contractor re D(HAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATER 4DISCLOS E
Will the applicant or future building occupant store or ha hazardous FiFATINC UNIT(TO 100,000BTU) Date Recei t
material as defined by the Cupertino Municipal Code,Chapter 9.1Z and the
lieaith and SafetyCoder.�Section 25532(a)7 I(EATING UNIT(OVER 100,000 BTU) TOTA
[7 Yea u No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RILSID) ISSUANCE DATE
which emit hazard...air contaminants as dented by the Bay Area Air
Quality Management District? BOILER-COMP(3HPOR 100,000 BTU) �_ O
Yea nn No 0
have read the b.9us materials requirements under Chapler6.95 of BOILER-COMP(OVER 100,000 BTU)
the California health k SafetyCode,Sections 25505,75533 and 25534.I ^
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQFT br 199
reaponsiblllty to not ity the occupant of the requirements which most be met �o O
prior to Issuance of a Certificate of Occupancy.
CII Y Ur i:Ur[�yy�q
Owner or authorized agent Date TOTAL: jj` ISSUHD BY: ��FJ
OFFICE COPY