23715 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro-t Identification PERMITNO.
Building Add.; 23715
nee• cross hone:, A
CITY OF CUPERTINO-BUILDING DIVISION S�zt-qz
c am Name: �ss� � Lic.No, APPLICATION I PERMIT y�
`^cawBInDINGEFGTRICAL.PLUMBING-MECHANICAL CATEGORY CONTROL#
Archlted/Iinglnee. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE �"
LICENSED CONTRACTOR'S DECLARATION
I hereby aHbmthat l am licensed under provisions of Chapter9(commcnc. APPLIANCES-RESIDENTIAL JOB DESCRIT"HON
inensei Infunpme ofd effect. .Trine Budnessand ProfesdonsCode,andm �
license is a fuI�orce�and effect. PANELS VF
License Clam UTI Llc#�-& K"tTI,
Oats S ]_ _Contraaor_tkU
ARCHITECTS CLAR TION OVER00 AM
PS
/F�
Iundemtand my plan shall be used not public recerda OVER 1000 AM75 $/SQ.Fi.
Licensed Professorial SIGNS ELECTRICAL MPU
' e E 1 L
OWNER-BUILDER DECLARATION &PECIALCIRCUIT/MISC M ,VEILIherebyaffirmthat l am exempt from the Cdntradorb License Law for the�( following reason.(Schon 70715,Business and Professions Code:Any city orFa c ntywhichmqul apert tmcmuhuct,dter,Impmve,de=lWh,orrepalr TIME'METIRORI'OLEINSf. E TOT
q'S anystmc mprlorlultshasa=calsorequimtheapphanto,suchpermito POWER DEVICES
15 file a signed statement that he,le licensed pursuant to the provisions of the
3 la'I"n Contractor'.License Law(Cho pmr 9(commencing with Section 700D)of Divi- SWIM,VENC POOL ELECTRIC VALUATIO
slon3 ofthe Rusism and ProfeubnsCode)orthat he h emmpttherefmmand
<, the bash for the alleged exemption. Any violation of Section 70715 by any L O OUTLETSSWITCHESFIXTURES,
applicant for a permit subjectsthe applicant to a civil penalty of not more than
five hundred dollars($.SW). f
I,as owner ofthe property, NEW RESIDENDAL ELECTR SQ.FT. STORIES rMECONSLRUCTION
�n p ork,a.rhe employees with r their
mIn&c.70Ktion,B.,imewill do lhe work end lines Code:Thoot Intended or offend far
O sale not apply
to an owner of and Professions Code:TheCimprowrs Leuconicame Law
�$ whdoe.do applytoa hi.1.rth.gywho Wlldsorimprove1dhdton,and OCC.GRCUP RFS.UNITS
who doessuchworkhlmxBorthrough hisownemployesa,provided thetsuch
Improvements are not intended oroffered for sale.if,however thebullding or
unprovement hsold within one yearofmmplelon,the owner-builderwill have
tiglZurden of proving that he did not build or Improve for purpose of mind. PLUMBING PERMIT FEE FLOOD TONE APN
u I,as owner of the property,am exclusively contracting with Ilce aril pp(MR ISSUANCE �
contractors to construct the project(Sec.70K Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN 4 VENT-WATER(RA)Wilds or improves thereon,and who contracts for such ptujets with a FEE SUMMARY
cgR(-doral licensed pursuant to the Convadoe.License Law. _ BACK FLOW PROTECT.DEVICE
LI I am exempt uWar Sec son
OU1rqjDF FEES
B& P C for thin reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
nee Date RECEIPT If
WORKMAN COMPENSATION DECLARATION FIXTURES—PER TRAP r- SCHOOL TAX Y_ N_
LS'L hereby aR1rm that I have a certificate of consent to aelfdnaure,or a RECEIPT#
a cortins!.ofWorkera'Compensation Insurance or a certified copy thereof(Sec.
3800 A b C I GAS EA.SYSTEM-1 INC./OULETS PARK FEE Y N
pyo.# a RECEDING DIN
CAS EA.SYSTEM-OVER 4(EA)Com anv BUILDING DIVISION FEES
Com
ropy hereby furnished. GREASE/INDUS(RL WASTE INTERCEPTOR PLANCHECK FEE
Q Certified copy to filed with the city Inspection division.
CERTIFICATE OF EXEM"ION FROM WOR KERS' GREASETRAP PAID
COMPENSATION INSURANCE SL'WER-SANCCARY-STORM EA 200FT' Date Recei t#
(Chissectlonom
neednot tcpleted lithe permit hforonehundreddollars
($1011).,Is..) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certify that In the perfomua nof thework forwhlch this permit is Issued, _
I shall not employ any person o any manner m asto become subject touts, WATER SY571]d/TREATING
Workers Compensation Laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL]'LMB. SQFf. Dale ReCei t#
Z O NOTICE TO APPLICANT:ILaRer making thin Certlfkateof EvemPtl.n,you
f" should become subjact to the Workem'Comperuatlon provisions of the Labor - TOTAL:
WLD Code,you=at forthwith comply with such provisions or thin penrdbhall be BUILDIN FEE W—
j deemed revoked.
0. 5 CONSTRUCTION LENDING AGENCY SEISMIC FEE
Ihembyaffirtn thatthereha madructlon lending agency for the perform- T �a ELECTRIC FEE
D Z ance.f the work(or which thin permit is Issued(Sec.3097,CIv.C.)
U O Lender.Name PLUMBING FEE
U. Lender.Add... QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Iadi/ythatl have read thhappliatbnand st.miluitlheaboveirrhummon and Yat.Iowa PERMIT ISSUANCE PEES PAI�, _
1 is comet.I agreeto comply with all city and county ordinance D:
>. N relatingto WlWingmmtructlon,and hembyauthorleerepmentathrcsofthis ALTER OR ADD'#MFLH. _
I— Z city to enter upon the above,mentoned property for inspection purpose.
(We)agree to save,indemnify an d keep harmless the City of Cupertino Date Recel [#
V against liabilities,jugments,costsand expense.which may In anyway acme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
ago Id City 1 nseque ce of the granting of tins permit.
`Z/ AIR HANDLING UNIT(OVER 10,IxaD CFM) CONSTRUCTION TAX
Sg of Apphom o actor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA OUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,006 BTU Date Receipt
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Sedlon25532(a)7 HEATING UNIT(OVER 100,000 BTU TOTAL
❑Yes lQ No
- Will the applicant or future building pact saw equipment or device VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit haaardou.air Grub umnts as defined by the Bay Area Air
Quality Management Dhlrid7 BOILER-COMP OHPOR 100,000 BTU
Yea n No
Thivemad the hazardous materials requirements underChapter6.95of BOILER-COMP(OVER I00,DWBTU) P A ' D
the Callfomh Health&Safety Code,Seniore 25505,25533 and 25534.I
undcmta rad that if the building does not currently have a tenant,that it is my NEW RFSIDFNTLAL MECH. SQ.F7 QqA
priml.bllity to notify the ocmpantoup.rcyulrementewhich must be met- IV
IA
nye--�
- prise to ante ofa Ccrlifiate ofOmpanry. � aF1 ( F/�w''+Al�`�74�
[Ownercraultori2fgent ^Z Due .ro 7m ISSUEDBY: thluvV
OFFICE COPY