23721 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification I PERMITNO.
buildingAddress;
79-52 L .vAP Imo. CvPEa Ifew 0 ca. 9 s'o i y 23721
B Lrie: One:
42uTSQ so rxj CITY OF CUPERTINO-BUILDING DIVISION �����1"j.�
con a or'sNa /{p i .No: APPLICATION /PERMIT � '—j _
L Lk.No:L3" z BUILDINGELECTRICALMUMBING-MECHAMCAL CATEGORY CONTROLN
. Architect/Eiglneer. -
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address, ❑ ElPERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
ON
on7Omen that lamgm3ofhe under BuA mond s/Chapter9(commenc APPLIANCES-RESIDENTIAL JOB DFF��RB770N
Ingwlt.mf.D700Wofdddon3oflheBustnessand ProleWoneCode,antl my w C,-
ours.
ecenae i In fail and effect. 2 PANELS a.17
Licence Lkou
Date 2 CoMnctor
ARCHITECTS DECLARATION ZO]-7000 AMP'
'lunderstand myplarsehallbeused aapublicrecords. OVER IOWAMPS ^ SQ.FT.FLOOR ARFlyi $/SQ.FT.
Fi Z(,( Licensed Professional SIGNS ELECTRICAL J 1 0 �l
<<�6lEBo
OWNERR BUILDEDECLARATION SPECIAL CO(CUIT/MLSC
Zt, Thereby at(Inn that OWNIE eexempt ER the Contractor's License Law for the
pp
Ofollowing reason(Section 70315, y Business and Professions Code:Ancity or ��
ZF TEMP.Mb7ER ORPOLE INSf.
PE anystm MmpHorlWitsis mlttoroonqui lter,lmprove,de such,orretto
1 anyatsigned statement
that
Jaako sed pu mush the Ionuchpeof to POWER DEVICES
w file a signed statement that M V licensed pursuant to the proWlom of the —'�� /I
O aContractor's License law(Chapter9(commencing with Section 7000)of Divi-
�Oa Non3ofthe Bualnewand ProfesslomCode)orthathe Ueaempttherefromand SWIMMING POOL ELECTRIC VALUA110N
o.-tt the boa's for the alleged exemption. Any violation of Section 7031.5 by any OViLE•IS54VEfCI¢SF7%7l]RFS
m C"i applicantfor&permit t subjects the applicant to a civil penalty of not mothan
five hundred dollars(¢SOW. NEW RESIDEMIAL ELECTR FT.
�n
F-11,as owner of the property,or my employees with wages as their sole S ' S'fOEES TYPE CONSTRUCTION
C compensation,wllldothe work and lhestructure isnot Intended or offered for
N O sok C5m 7OK B..m...d Profs .Cnde:Th.Contract.?.Li..Law
$ don not apply to an owner of property who builds or Improves thereon and OCC.CRONs RES.UNITS
who does suchwork himself or through Na awn employms,provided that such
Improvements are not Intended proffered forsale.If,however,the building or TOTAL;
Impmwc ntkwtdwithinamrarefcompleWktheowner-buBderwBl have
thg4urden of proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOG TZNL' APN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.70y Business and Professlom Code: e's
The Contractors License Law does not apply to an owner of property who
Wm ALTER-DRAIN k VVENT•WATER(EA)
builds or Improvthereon,and who rontnm for such pWjem with e .
cHec s)licensed pursuant to the Contractor's License Law. FEE SUMMARY
am exempt under SB k P C trfor this reams BACK FLOW PROTECT.DEVICE
DRAINS.FLOOR ROOF,AREA, ND. SAMTARY Y N
Owner Date RFCOl'1.N
WOR KMAN COMPENSATION DECLA RATION FIXTlR(ES PER TRAP SCIdOOL TAX Y_ N_
F11ve 1 hereby affirm that I haa certificate of consent to sell-Insure,ora RECEIPT X
3800,Lab C.)
ceHfimleofWorke Compersahmil ranceoramdifiMcopytheaof(Sec. GAS EA SYSTEM-1 INCA OUTLETS PARK FEE Y— N
Policy N RECEPT M
Co any GAT'EA•u�o�T�'O�Ra�`) BUILDING DI VISION FEES
ECertified copy Is hereby tthcity
e city inspection division.e
❑Certified copy is feed withh the CREVSEANDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Recei tilt
(This section need not be completed if the permit Is?carom hundred dollars
(EIOW o Ify that
WATER HEATERW/VENT/E,ECTR ENERGYFEE Y N
IceHfy thato the person
ancerso as to behbpenmit is blect to ed,the —
I shall not employ any pesos In any manner at m to beroure subject to the WATER SYSTEM/TREATING
workers'Compensation Taws of Glifornk.'Date PAID
0 Z NDnAppliCant
Z p NOTICEco esubjeAM:IL .r1makiemperCiwopreo(ons of
eLyou
NEW RESIDENTIAL PLMB. SQ.PT, Dale Recei fN
should becomesubjectto the Workers'CompematlonproWlonar the Labor TOTAL:
LU N deemed revoked.
at with comply with each provisions or this peDNt shall be
LU 7 deemed revoked.
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z Iherebyaff(Dn that there ba construction Lending agency for the perform- T ELECTRIC FEE
7 ance of the workfor which this permit is Wued(Sec.3097,Civ.C.) ��'
V O Lender'sName PLUMBING FEE
LL t- Lends/.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
I certltythatl have readthiseppticatmnand state thaltheabove mfornuit
V ronM.Iagre<tocomply with muntyordmanorsand state laws PERMIT ISSUANCE
FEES PnID:
O W
} 1 relating to building construction,and hereby authmice representatives of this
?W city to enter upon the above-mentioned property for Inspection pu rposes. ALTERORADDTOMECH.
(We)agree to saw,Indemnify an d keep harmless,the City of Cupertino Date Receipt#
V
against liabWties,judgments,costa and expenses which may In anywayamme AIR HANDLING UNR(TO 10,000 CFM) SUBTOTAL'
agai
Signature.C(ryJicunt/ qu ?the granting. e rout __ '
i. rouL a)� AIR HANDLING UNIT(OVER IO,WO CFM) CONSTRUCTION TAX
Signature of Applicant/ cant Dam EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,ODO BTU) Date Recei tN
material as defunCd by the Cupertino Municipal Code,Chapter 93Z and the
H❑Yes No
ealth and Safety Cade n25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
Will the applicant orlusum Wilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haesrdoua a4 cont nm as dented by the Bay Arca Air
Quality Management Dislo BOILER-COMP OHPDR 100,000 B'HJ) -
4 Yrs No rm p
have read thehav ua malerlaLs requlrcmenb under Chapter 6.9SOL BOILER-COMP(OVER 1(0,000 BTU) B' py B
the California Health k Safety Code,Sections25505,25533 and 25534.I
usponsi rad that notify
the occupant
of the requirments which
that itbmy NEW RESIDENTIAL MEGA. SQ.I"T MAY 22 gc�
responsibility to
lila notlfylheocte of Ocupancyulmmenta which moat be runt as
prior to nm Ma�Bca'e ofOmpancy. �/ G a
Owns rauthorl a t Date _ T ISSUEDB
OFFICE COPY