23275 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulldln Proem lJentlflcatlOn
Building Address, - PERMIT NO.
23275
ners ams: I one:
CITY OF CUPERTINO-BUILDINGDIVISION
con or'eName: LIc.Nm APPLICATION /PERMIT
Arc Itectgime,. BUILDINC-ELECTRICAL -MECHAMCAL CA Y CONTROL p
LL,No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address
PF7ihBT1$SUA ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION ' NGE
I hereby affirmthat l am licensed under provIslons of Chapter 9(coneen APPLIANCRSRESIDENTIAL
IngwlthSMlan7DM)of DIv1NOn3ofthe BuslnessandPmf-M SCa e,and my ]OB DESCRI'TION
license le Infiyryy d effect.
LI...Cl. Luc /�
Date Contrast., /�Q(/ PANELS fIP�'N7�
ARCHITE T '-- / 101-]OOOAMPS
000 (understand my plans ehaB be ueM ea publicrecoNs OVER1000 AMPS SQ.FT.FLOORAREA $/SQ.FT.
6 Llcansed ProfesslOml SIGNSELECIRICAL
� Btt'+ OWNER-BUILDER DECLARATION
Ihereby affirthat l am exempt(mm the Contractor.License Law for the SPECIALCRCIRT/MLSC
t.
foil
affirm that
resew.(SeRion 70315,Business and Prulmlons Code:Any airy or
countywhichrepulreaapermittomrut M.1ter,Impmve,de=Uh,orrepalr TEMP.METER OR POLE INST,
any atmaurctahmenbhYla,Is alsaregWmthaat to the fmsudom of to POWER DEVICES
O floe o signed statement that he b r 9(cod pursuant 00 the provIs 00)of the
3µ Contnct.re Lacerate Lew(Chapter 9(commencing with exempt
therefrom
of DEW-
�O
then 3ollhe Business and Pro(emlons CodUorthst he bexempt there(romand SWA4'BNG POOL ELECTRIC VALUATION
<A the basis for the alleged exemption. Any violation of Section 70315 by any
❑�` appBcantforapermlt subjects the applicant too civllpnultyofnatmonthan OUTLETSSWIICFffSF1J(7'URFS
file hundred dailan(55001,
�n ❑1,as owner of the property,Or my employees with wages as their sole al RESIDENTIAL ELECTR__SQ,FT, STORIES TYPE CONSTRUCTION
mmpcn tion,wBidothewont,andthestmnureIsw Emendedor offend for
sale(Sec.7044,Business and pm(em7oru Code:The Conlndore Llcame Law
$ does not apply to an owner of property who bulldsor improves thereon,and
whodoessuchwmichimeeBorthrough Msownemployeas provided that such
C.CROUP RES.UNIT'S
bnprovements are not intended or offered for sale.If,however,the building orTOTAL:
improvement Is sold withlnone yearofcompletim,the owner-bu0derwill have
t rice of proving that he did not build Or Improve for purpose of sale.). BING PERMIT FEE
L as Owner of the property,am exclusively oontncting with licenseeFLOOD ZONE APN
contractors to construct the project(Sec.7044,Business and Professions Code: CE
The Contractor.Lt..Lew does eat apply to an owner of property who
builds or Improves thereon,and who contracts fos sash p(ofeats with aALTER-DRAIN VENT.WATER(FA)
actor(s)licensed pursuant to the Contractor:License Law, FEE SUMMARY
1 am exempt under Sec B&P C for this masonOTECT.DEVICE
Owner Date R ROOF,AREA,CONDOWORKMANCOMPENSATIONDECLARATIONI hertby af(Irm that I have a certificate o/comers/to BellIor a XFURF8 PER TRAP SCHOOL TAX Y N
mnlflute of Workeri Compensatlonlnsurance me certified copy thereof(Sm. RFCEB'T N
MOO,Lab C) CAS EA.SYSTEM-1 INC.40[TTI.EfS
a 7�3 PARR FEE Y N
Policy Y RECEIT T N
Com any GAS PA.SYSTIM-0VER4(FA) BUILDING DIVISION FEES
[�Certl(ed ropy Is hereby fumished.
®f)ertlfied ropy Is filed with the city Inspection division. GREASE/INDUSTRL WASTE I ITFRCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID
COMPENSATION INSURANCE
Qhissedionneed eat hecompleted lfthepemdl Isforonehundred dollars SEWER-SANITARY-STORM RA,200FT. ' Date Recei tp
($]00)m l..)
I cardfy that In the performance of the work forwhich this permit le Issued, WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
I shall not employ any person In any manner cue es to become subject to the -
O Worken'Compenmtlon Laws of California. WATER SYSTEM/TREAIINO PAID
Applicant
Z Q NOTICETO APPLICANT:(,after meWng thio Ccrt0lcate of Exemption;you NEN'RESIDENTIAL PLMB.__SQ,F[, Date Recei tp
y should become subject to the WOrken'Compensatlon provIsbns.(the Labor TOTAL:
Code,you=at forthwith comply with such pro luiom.,this permit shall be
W domed revoked. '�
IL p CONSTRUCTION LENDING AGENCY SEISMIC FEE -�
I hereby affirm that there b a construction lending agency for the perform ELECTRIC FEE
M O anmO(lhe work fmv,hich this permitb Issued(5ei 3D97,Clv.C.) TOTAL:
C) _ Lender.Name PLUMBING FEE
LL levier.Aaann QTY, MECHANICAL PERMIT FEE MECHANICAL FEE
O W Imdlfythatlhavemadlhbappliationandd.tethattheaboveinfomation
4 bcorrect.I agresto comply with all cilyand county ordinanmand slate laws PERMIT ISSUANCE FEES PAID:
} W relating to building corutmctlon,and hereby authorize representatives of this
Z e ty to ente nth.abovnmentlomd property(or lnspatIon purposes, ALTEROR ADD IO MECH. -
V ee o nave,I-=e an d keep harmless the City of Cupertino Date Receipt#
against abl es,judg tsaveteandex whic Inanywayaccrue AIR HANDLING UNIT(To IO,ODO CEM) SUBTOTAL:
:gal y use n t melt.
AIR HANDLING UNIT(OVER IO,OWCFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date HAUST HOOD(W/DUCT) CONSTRUCTION TAXPAID: .
HAZARDOUS MATERIALS DISCLOSURE
Will theappllcant or future building occupant store.,handle hazardous HEATING UNIT 100,000 BTU)
muterlalm de fined by the Cu MunidpalCode,Chapter 9.13,and the Date RMai tic
ElcahhaM SafetyCade n25532(a)2 HEATING UNIT(OVER 100,000 BTU) TOTAL.
I1 Yes No
Iilsheepplicant or tore bulldln ompantumequlpn�ent ordevlme VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hecard.us au.meta a as defleed by the Bay Ana Air
Qu IityesManegemxm DIstrl BO[LER-COMP DhI'DR 11p,000 BTU)
N
4h:ve and Nehara .us materiab nqulrerrcnb under Chapter 6.95 o(. BOILER-COMP(OVER 100,000 BTU)
the California Health&Safety Code,SMions 25505,25533 and 25534.I
undcrtan thati(the building docs not currently have:tenant thathunny NEW RESIDENTIAL MECH. SQFT p
resp. yto mAWagcnt5E:2D.Xt .
muU�PHO once (anero
r authorieedTOTAL: ISSUEDBY:- Q
OFFICE COPY 1aUFthf flvU