23499 APPLICANT TO FILL IN INFORMATION WITHIN AD LINES)— USE BALL POINT PEN ONLY
Building project ldentiflmdon `a' PERMIT NO.
Budding Addnv: - 23499
e . sone:
C�FiS Z151 7 ljl� CITY OF CUPERTINO-BUILDING DIVISION
Co
p"Ch'°c Lm.N. APPLICATION /PERMIT
Amhitect/Engineer. 1 ��,6r BUTLDING-ELECTWCALPLU INA MECHAMCAL CATEGORY C
5 n c�'1,� O
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add..
I'FRMITISSUANCE ' �'
LICENSED CONTRACTOR'S DECLARATION
I hereby afflnnthat lamlicensed under pressandsuf Cssion.9de,.n mc- Alalr[.IANCES LingwitJOB DISC N
liomse ISecHon 70007 of DlWect. he BugneseandProtesdonsCude,and my �0� ` o `
Licen sin mI fate and effect. SmO�� P r W
Date LIe M 7 ,/ 7
Date CoMnttar
RCHITECTS DECLARATION 1'1000
u0u11 O I understand plan .luill a used u public m ones. ' OV SQ.FT•FLOOR AREA �e//�� f/SQ.
'Z Licensed Professional
SIG
S CA4
.�6 OWNER-BUILDER DECLARATION SPEC LC /M15CLaJ :J �,,,' f V
io.,, IherebyafRrm that l ameeemptfmmthe Contractors License law for the
F Z F following reason.(Section 7015,Business and Professions Code:Any cityor TEMP.MEITR NSf.
muntywhlehrequiredapermlttommt ,aller,Impmve,demoWh,orrepalr
N166 anystmcture pricrto its Issuance,also requlreslheappllmnt forsuch permit to POWER DEVICES
6 V Nro
e a signed statement that he is licensed pursuant to the pvialons of the
g3w Contra orci
's License Law with Section TOOL ELECTRIC ion 7000)of Divi- VALUATION
�0 gon3ofthe Buslnesaand Pr°femlomCode)orthathelsemmptthemfromend �s
the basis for the alleged eaemptim. Any violation of Section 7011.5 by any I OUTLETSSWITCHESFIXTURES 6 1 O
04 appHmntforapermitsubje theapplleanttoadvilp..Hyo(nmnnrethan
five hundred della.($900).
I,as owner of the NEW RESIDENTIAL ELECTRSQFf'. STORIES TYPE CONSTRUCTION
property, employees r their
d for
salegZ dory Buswill=gework andthesCodurche Conuct ended oroffe Law _
p sale 600.7064 Budbum and Professions Cade:The Contractors License Taw
$ don not apply to an owner of property who builds or improves there ,and
S^ who doedsuch work himself or through his own employees,provided that such OCC.GROUP RES.UMTS
Impro,emend arc not Intended or offered for sale.It,however,the building or TO -
i pmvermnt[swldwithlnomyearotcompldlorytheowner-bullderwlllhave
t rem of proving that he dm not build or Improve for purpose ofsale3. QTY; PLUMBING PERMIT FEE FLOODZONE APN
roL j L as owner of the property,am exclusively mnenRing with 11 sed pEgMIT L6UANCE
ntradon t°construct the project(See 7046,Busmen and Professions Code:
The Contractor'.Limn.law does not apply to an at 0f property who ALTER-DRAIN&VEM-WATER(EA)
builds or improve.the em,and who contracts for such p(ojects with a I FEE SUMMARY
�gB�edor(8)licensed pursuant to the Contractor'.License Law. BACK PLOW PROTECT.DEVICE
LJ I am exempt under Sec. B&P C for this msson
Owner Date DRAINS FLOOR ROOF,AREA,CONE). SANITARY Y N_
RECEIPT a
r–� WORKMAN COMPENSATION DECLARATION FIXTURES PER•TRAP �� SCITOOL TAX Y_ N_
- Lll hereby affirm that I have a certificate of consent to selLlnarc,or a RECEIPT a
mrtlBoleofWorkets'Compens dmlmummmamrtlfledmpylhereof(Sec. GAS EA.SYSTEM-1 AICA OUTLETS as � PARK FEE Y_ N
Policy
N C.) RECEIPT M
Pr11ry N GAS EA.SYSTEM-OVER 4(FA)
Com any BUILDING DIVISION FEET
�Ceriified copy is hereby furnahed. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
Certified copy is filed with the city Inspection divi.im. I Q
` CERTIFICATE OF FXEMPTION FROM WORKERS' GRFA.SETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-SIORMEA.XIOFI'f . Date Recei t#
(This section need net be completed if the permit is forone hundred dollars
(elm)°rlmd.) 11 kyA.�l&ATERW/VENT/EL�C1 1
ENERGY FEE Y N
I certifythat le the performance ofthe work forwhich this permit I.Issued, l
- I shall nm employ any person In any manner w m to become object to the WATER SYSTEM/TREATING
Workeri Compensation Tawe of Callfomla.Date PAID
Z ZNOIlicant
ICETO APPLICANT:If,after nuking this Certificate of EaempHa.1 you NEW RESIDENTIAL�B' SO'r' Date Rets t#
0 should become subject to the Workers'Compensation provisionsof the Labor TOT L:
(q Code,you must forthwith comply with such provielore or this permit shall be
LU > deemed rooked. —
IL c CONSTRUCTION LENDING AGENCY SEISMIC G O
Iherebyaffirm that them is a construction tnndlegagenry for the perform, ELECT' C L
M Z anonofthe workfor which this permR is issuM(See 3097,Cl,C,)
U0 lander'.Name Pl: G FEE
iL f Lenders Address QTY. MECHANICAL PERMIT FEE ME MCAL
OW ImrtOy that]Mve readtNs appllmHonand patethattheabova information
1 ismrred.I agreeto comply with all city and county ordinancesand gate laws PERMIT ISSUANCE '� FEES AID:
> H relatleg to building construction,and hereby authorlu rcprcsenlalNm of thif
H city to enterupon the above-mantloned property for Wpettbn purpome. ALTER OR ADDTO MECH.
? (We)agree to save,indemnify an d keep harMess the City of Cupertino Date Receipt#
V
against liabilities,jadgereentossandeapenseswhich may manyway... AIR HANDLING UNIT(TO 10,0DO CFM) UBTOTAL'
agalns City in mnan(pu�(nm of granting of this eenNt qq�q AIR HANDLING UNIT 10,000 CFM? CONSTRUCTI TAX
'6_w CONSTRUC IO TAX PAID:
IgnaNre°f Applmnt/Conlracior - Date EXHAUST HOOD(W/DIX:T)
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant car future building odvpant store or handle hazardous HEATING UNIT(70 100,ODO BTI!) Date ec:el t#
material as dented by the Cupertino MuNdpal Code,Charter 9.12,and the
health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) T '1'
❑ Yee u No
Will the a ppilmntorfuture building occupant use equipment or devims VENTILATION FAN(SINGLE RIESID) ISSUANCE DATE '
t which emit haeardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP((3HP OR 100,((10 BTU)
0Yes
7No Pf A
ve read the haze our materials requirements under Chapter&95 of BOILER-COMP(OVER 100,000 BTU) If' A
sk the C.Ifornla Health&Safety Code,Sections 25505,25533 and 25536.I
understand that if the building docs not mnently have a tenant,that it is my NEW RESIDUMAL MECH. SQ'IT JUN 22
responsibility to notify the occuparat of the requregiments which must be met lAA9
prior to Issuance of a Certificate of Occupancy. - /s u OO.s77LL..
Owner or aulhorized agent Date ISSUED11Y. UI' LUr CTt 11MV
OFFICE COPY