23344 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildingProject Identification PERMITNO.
B°Tiding Address: 23344tc
2�2A�t �a'-� g�-o�za
Werra ane: x� �J one:
{3—L � CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
n.la BUILDING-ELECTRICALHUMBINGMECHAMCAL CATEGORY CO
Architect/Engineee Lic.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add.
PERMITISSI]ANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby.(fum that l am Bceneed.oder pmvi.1maofChapter9(en.c APPUANCMRESIDENTIAL ]OB DESCRIPTION Section 7000)of Dividon3 Ofthe Busineuand refessionsCodq.nd my
license le in full(ora and dlM. PANELS
License Clam LIe.X
Dale Contractor Y,•
ARCHITECTS DECLARATION 211-1000 AMPS
AcQ lunderatand my planssh.0 beused as public record. O 1 N[fTSQ.FT.HOO AREA 5/SQ.FT.
Licensed Professional 57 NS ELECTRICAL IIS, s
43
I OTE
WNER-BNLDER DECLARATION ( t �
Iz7 Iherebya(Ormlhat lamexemptfromthe Contractors License lawlathe r.�eBjelb
0�..^ couow ounty which on.(Ses a permit
tectunduct and Pro prove, Code:My Rty or �p R POL I as
I" anysimhich requlresa issuarto also rquiresthe applicant for
VV \
any etsuRurc prilort.t-tema Ile hat he it also req.pursuant
.ions of t e
p file a signed ftatemenl that he b licensed pursuant m the provisions of the - POWER DEVI
3tIn Contractor.License Law Ochs par 9(commencingwith Smile.70M)ofDlvi-
�O�p sion3 ofthe Busuessand Professions Code)orthat heb emmptthemfmmand SWBdMING POOL ELECTRIC ypLUAT10N
the Weis for the alleged exemption. Any violation of Section 70315 by any
applicant fora permit subjects the applicant to a civil penalty ane OUTLE'ISSWITCIiESFTX'1'URF5 more than 't�S rO�a
five hundred dalare(4500). L
�n F�I,as..or of the property,or my employees with RESIDENTIAL ELECTR with wages as their sole —FRET. STOWS TYPE CONb I KU LION
compensation,wal do the work and the structure Is not Intended or offend for
HO as to f&c 70K Business and Prace lons Code:The Contractors License Law
P�2 does not apply to an Owner of property who builds or improves thereon and OCGGROIIIa RES.UND'S
who does such work himself or through his own employees,provided that such
improvementsare not intended watered for sale.If,however,the building or TOTAL:UPS—
Improvement
hsold within one year o(complatlon,the Own,bulMer will have
tlI:.;urdenofpmvmgth.t M did notbaldorlmproveforpurposeofaale.).1, QTY, PLUMBINGPERMIT FEE HOO
uu as owner of the property,am exclusively contracting with licensed D7DNE APNppd(MD.1SSIlANCE
metrecton to aratmR the project(Sec,70M,Business and Profeasbta Code:
The Contractor's License law does not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such ptojia. ER
with a ALT 'DRAIN&VENT-
WATER(FA)
Lj 1
R"(s)Banaed Pursuant to the Contractor.Lianse Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
am exempt under Sec B k P C for this reason
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N—
t WORKMAN COMPENSATION DECLARATION Rl]CEB'TX
QI hereby affirm that I have a'artl0ate of consent to ul(-insure,or a �RES'��s SCHOOL TAX Y N
certificate o(WOrkere'Compensatlonlwurana me mrtlfled copythemcf(Sec. RECEIPT'x
3800,Lab GAS F.A.SYSTEM-1 INCA OUTLETS PARK FEE Y_ N_
Policy X - R1L77PP x
Com any GAS EA.SYSTEM-OVER 4(EA) BUIL RECEPDING IVISION FEES
Certified copy b herebyth the ed.city GRFASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified ropy b(fled with the city W peRlOn division. I 4
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID `� l i5
COMPENSATION Bib,
SEWER- STORM EA 200FT Date RCCCI t
(ThissaRlon need out bra complated I(Ne pemdt h laruro M1undred dollars
($100)afy that
WATER HEATER W/VENT/HECTR ENERGYFEE Y N
Isnot thato the pennon
wok fo as to
penult1a Issued,
exase
1 shall not employ any perws In any manner m ss to become subject to the at.a
Worlicant Compensation laws of California.Data WATER SYS1Fh1/TREATING PAID / {�{
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
Z O NOTICE co APHICttothe a.rkerakingt relation provisions
ro ilius.fEc the Labor should You me,
subject it the ply wit Comp Providers
orthiOnsofthe allbe TOTAL:
WN Code,you nwat(Orthwith comply with such provbmns orthb permit shall be
> decreed revoked. BUILDINGFE
CL G CONSTRUCTION LENDING AGENCY SEISMIC PEE
I herebyaf0rmthat there ha construction lending agency for the perform -jTa SEISMIC
0 ance of the work for which this permit h Wued(Sec.3097,Civ.C.) TOTAL: r
U — Landers Nara PLUMBING FEE
U. H Ix era Address Q'rt'. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Ice Ihatlhavcm.dthisa Ilatlonandmatethatthc.bovelnfomutlon
(L b<OrreR. gree to comply with Il dtyand county ordinances and state lawn PERMIT ISSUANCE �D6 FEES PAID:
N relatingfob Iding roretroctlOn,' dhereby authorherepreaentativesolthh
Z city to enter thea ve- t ed property for Inspection purposes, ALTERORADDTOMFCH.
— (We)agr to ve n fy d kap harmless the City of Cupertino Date Receipt#
agalnstlb hies, dg on, a expenseawhich ylnavywayaccroe AIR HANDLING UNIT(TO I0,000CFM) SUBTOTAL:
.1ruta dCity roI yue f gramingoft permit.
3#-`t2- AIR HANDUNGUNIT(OVER lo,000CFM) CONSTRUCTION TAX
Sig a' Of tppBc.rat/Co a, r Date E(HAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUSMATERIA ISCLOSURE
Willtheapptice t or future building accv rat store or handle hazardous HEATING UNIT(TO 100,ODO BTU)
rr Date Recei I#
ommal as defined by the Cupertino Murddpal Code,Chapter 9.12,and the _
I Iealth and SafetyCode$eRion 75531(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yea No
WBltheapplicantor tum building occupant use equipment or devices VENTILATION SINGLE RFSID) SO ISSUANCE DATE
which eManagement air contaminants aaeas defined by the Bay Area Air
ality Management DhMR7 BOILER-COMP PfE OR l00,0(q BTU) PAID D
Yn No ii
have read the lean our Code, ectl ulremenbundcr Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health&Safety Cada Sectbm 25505,75533 and 75534.I
u xiersts rad that if the building does not currently have a tenant,that it h met my NEW RESIDENTIAL MECH. SQ.FT. MAR `e0 199E
responsibility to notify the occupant of the requirements which at be
prior to Issuance of a Certificate ofOccupancy.
CLI Ya sale CUrc`nl uvU
Owner or authorized agent D.te ISSUED BY Ot
TOTAL, y,
OFFICE COPY