23022 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PWNRTNO.
Building Address: -23022
ZZ,Q �i�7lY CV(iC/l Gtr r�l NO C� gjap/,v
OwnersName: Marc;
P CITY OF CUPERTINO�BUILDING DIVISION
Contndore Na Lie Nm APPLICATION /PERMIT
BUILDINGELECTWCAIPLUMBINGMECHAMCAL CATEGORY CONTROL M
ArcMted/Engineer. Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:
PERMITISSUANCE Tib' 1:1 1:1 11LICENSED CONTRACTOR'S DECLARATION L�'
I hereby hSed1 70Butlama1m3dunder heilueressanderfChapler9(e,and APPLIANCES-RESIDENML JOB DESCRIPTION
It...IStolon to.anDivfect. ofthe Busincuandl'rolmdoneCade,and `�
lice..Is in full form and died. PANELS �/��P�`
DateLke. la. Llc N '. �`�t
Date Ga ITECI M11000 AMPS
III!TO 2DDAMPS
ARCHITECTS DECLARATION
rsOz � Iundentand my plant shallheuerd as public records OVER 1000 AMPS N/SQ.FT.
E LEtY IN
zLicensed Professional SIGNSELECTRICAL
<N that
I..BUILDER DECLARATION g•ECIpLCIItCU1T/MIST M P/
7 t.., Iherebyatflrm[OWNER-xemplfroDEC LARATCmird.e.Limn.Law for the
pp following rcam.(Sedlon 70315,Business and Profmlon$Code:Any city or )/A ��
O'y" TEMP.MEITAORPOLE INST. Vel
P cnystm lmpr oiitotapwancrommrequialter apUmntfmsuch,or to
any structure statement
that he is attoused pursuant to the providers
of t e POWER DEVICES
file a signed statement that he b Rmnsed pursuant to the provbbm of the
Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
the bass for
the alleantl Prufessim.Co y violation
of emmpt therefrom and
a.•77 the Want(ortheallegedexemption. Myttolatbn of Section 70315by reany OUTLETSSWITCHES37X7VRES
Applicant(ore permit aubjectsthe applicant to a civil penalty of not mare than
five hundred dollars( .
NEW RESIDENTIAL ELECTR
❑I,s, owner of the property,or my empure isnwithwagesr theirdole �'�' SfOWf5 TYPE CONSTRUCTION
col.(Se. 044,will do Business
work and the structure isnot Intended or offered for
O .le(Sec apply to atrures and f property
rope ty Cade The or impnw/e License law
does whodotsuch loan owner of(prough hiswho
nembuild,orimpmvnted thatand such — OCC.GROUP 'RFS UNITS
whodaeseuchwork himself deo orwgh his own owe provided ildingm
• Improvement are soldtintenomyearofmmpiroffered ale theca eveplhderwillngw TOTAL
Improvenantheoldwithlnone yearofcompldlory theawner-bu0derwillhave '
itK,kurden of proving that he did not bund or improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE FLOOD TONE APN
U L as owner of the Property,am exclusively contracting with licensed
contractors to construct the project(Sec.70th,Business and Professiom Code: PERMIT ISSUANCE
The Contractor's License Law dare not apply to an owner of property who ALTER-DRAIN AVENT-WATER(FA)
builds or improves thereon,and who contra for such pkojeds with a FEE SUMMARY
cgRj[ctorW licensed pursuant to the Contractor's License Law.. BAIX PLOW PROTECT.DEVICE
L,f 1 am exempt under Sec B h P C for this reason
DRAINS FLDOX ROOF,AREA,COND. SANITARY Y N
® Owner - Data RECEB'f N
WORKMAN COMPENSATION DECLARATION
❑I hereby office.that I have•mnIDcate of consent to.If-snare,or a IO)(TURES PER TRA!' SCHOOLTAX Y N
our locate of Worken'Compere atlonlmunnm ora certified copy thereof(Sec. RECm'f N
3800.Lab CJ GAS EA.SYSTEM-1 7NC60UTLET$ PARK FEE Y N
RECEB'T N
Policy N GAS EA.SYSTEM-OVER d(EA)
any BUILDING DIVISION FEES
ededl(led copy b hereby copy is rd with the city tumcityInspection rupedian division.n. WGREASE/ DUSIRL WASTE INTERCEPTOR' PLANCHECKFEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCESEWER SANITARY STORM EA 200F1' Date Recti t#
(fhb section need root becamplded R/hepermit bfor ane hundred dollars
(9100 erless,) WATER HFATERW/VENT/m rr.IR ENERGY FEE Y_% N_
I certify that In the performance of the work for which this permit is Issued,
I shall not employ any person In any manner so as to became subjed to the WATER SYSTEM/TREATING PAID
Workers Compensation Laws of Callfamla.Date
O Z Applicant NEW RESIDENTIAL PLMB. SQRf. Date Recei t#
ki
Z 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should bemme subjnt to the Workers''Compersation provisions of the Labor TOTAL: -
LO Code,you most forthwith comply with such provisions or this permit shall hat BU WING FEE
r'
W > deemed revoked.
CONSTRUCTION LENDING Edonl AGENCY SEISMIC FEE
CL Ihfthew a'fe, ut wtherebacomituctsated(Sec. agendyr.C.) perform, ELECTRIC FEE
� Z once of the workforwhkh this pemnitbbued(Sec.3097,Civ.C.I TOTAL:
(� O Ierdce.Name PLUMBING FEE
,LLE Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I certifythat l have readthb applicationand natethatthe above information
1 iscorred.I agree tocomply with all city and county ordinances and date laws PERMIT ISSUANCE FEES PAID:
>. N reI.ting to building cors[ruction,and hereby authorize representatives of this
F Z city to enter upon the abovcmenttoned property for Inspection purposes. ALTER OR ADD TO MECH. Date Recti I#
(We)agree to save,Indemnify an d keep harmless the City of Cu penin,
against habilitks,judgments,massand ea n which may inanywayacerue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
ag.irut a id City lap a en t 4ofthisperroh.
IA III 2
4-dyI AIR HANDLING UNIT(OVER I0,000CFM) CONSTRUCTION TAX
Signature of Applicant/Cantractsf Applicant/ContractData EXHAUST HOOD(W/D(KD CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE /
Will the applicant or future building occupant stare or hand le hazardous HEATING UNIT(TO 100,00(1 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the _ Date Recef t#
Health and Safety Code Section 2S532(a)2 HEATING UNIT(OVER 100,000 BTU - TOTAL:
RY. M No
ill the i ppliceat orfuture building occupant use equipaant or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as dented by the Bay Area Air PAID
ality Managm
eent DIstridl BOILER-COMP(3HP OR 100,CM BTU PAD
Yes No
ve read the h ous materials requirements under Cha pler6.95 of WILGTI-COMP(OVFR 100,000 BTU)
the California Health k Safety Code,Sed Ions 25505,25533 and 25536.7 NOVOil 22 1991
understand that if the building does out 6,rrently have a lenan4 that 3t b my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requirements which moat be met
IU
priortoissuanceofaCenlf leof Oc party. tri1IN
C11Y ur GUS
Owner or authorized agent - Date ISSUED BY:
TOTAL:
OFFICE COPY