23980 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification - PERMIT NO.
Bulking Addrca: , 23980
possu �L
rs ante: one:
Q zC.! CITY OF CUPERTINO-BUILDING DIVISION _ ^
CentraetursName: Lk,No: APPLICATION I PERMIT
�LO r BUILDINGFLECTRICALML BING-MECHAMCAL CATEGORY CONTROL
Archl /Englnesr. Lk.No: BUILDING PERMIT INFO
QTY ELECTRICPERMIT FEE
,UM" MECH
Address: FERMITISSUANCE ❑ ❑ 11 '
LICENSED CONTRACTOR'S DECLARATION
I hereby Gk000)Of iv Rented under eBud provisions mfC onsCode, mmc APPL[ANCESRFSNENTUL I� JO DFSCRI'TI
InenseI In
farm anDlaffect o(Ihe Bumnneand ProlnNonaCmde,md I�/V '
limns Is in run(ora and affect PANELS
License Clay Lk.X t,a
Date Contractor UP TO 2DO ANTS
201 IOW AMI9
Am shall be
DECLARATION FT.FLOOR AREA WSQ.FT.
pQ±0O Iudentand my Pisa eluB be used republic tecuN> OVER 1000 AMPS SQ.
E
lib Licensed Professional SIGNS ELECTRICAL
HN OWNER-BUILDER DECLARATION SPFCTALCRCUIT/MISC E D I N
Z,_ Iherebyaffirmthatlamexerupt fromthe Cmdrad.eitiom.Lewfeathe INAL
p following...(Section WETS,Business and Professions Code:Any city,or I
Ogg TEMP.METFROR POLE INST. P UTE R
q a
C6GF1I 03µOI VYrs anyudre pdorro oaose h uc t
POWER DEVICESOe a signed et that he ut lican,ad puputo the provbloest of the
Contractor's License La (Chapter
9commencing with Section pof Die
mon3ofthe Business and PmessimCoe).rthat halbeampitther(romand SWIrMNG POOL
ELECTRIC &TION
q Sn 3 the basis for the alleged exemption. Any ,violation of Section 70015 byny a
OUTLETSSWITCHFSHXTURES
fiMbunlfor apemNt55M. etheappRant t...ull p.akydna more than
By"un dredddbnhepr. NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPECONSIRUCTION
�n a as owner of the property,or he employees with wages r thele sok
compensation,will do Businethework andions Code: isnot intended Loffered(or
D
sale(Sec 7064,Business and Professions Code:The Contractors Liaae Law
t�i $ don not apply to an owner of property who builds or improves l harem,and OCC.GROUP RFS,UNITS
FF who don such work himseBathrough Msown employees,provided that such
Improvements are not Intended orofferd for sale.If,howme,the building Or
improvement beold wlthnoneyearofcompldio,theowner-budderw111 have
Ifrden of peeving that he did not build or Improve for purpose ofsalI QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
f�u L as owner of the property,am exclusively contracting with licensed pp{g{R ISSUANCE
to mentrud the project(Sec 70K Business and Profession Code:
The Contractors License Law don rad apply to an owner a property who ALTER-DRAIN&VENT-WATER[EA)
Wilds or Improves thereon,and who contracts fur such ptokds with a FEE SUMMARY
cgBt(actor(a)Roamed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under See. B k P C for this masonOUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y 'N
Owner Date RECEIPTN
WORKMAN COMPENSATION DECLARATION FDCURES-PER TRAP SCHOOLTAX Y N
❑I hereby affirm that I have•certificate of consent ro self-Inure,ora RECEIPT N
mdlfinteofWorkeri Compematlonlns mnmeaacedlfkrlcopythereof(Sec. GAS-EA SYSTEM-IINC.40UTLLT5 PARK FES Y N
3800,L bC.)
PWIry M nRECEIPT
rev Z 1.1 GAS EA.SYSITM-0VER4(EA) BUILDINGDINGDI IV VISION FEES
ertidcopyis em�rhfisha� PLANCHECK FEE
Coniied copy b filed with the city impaction division. GREASEANDUSIRL WASH INTERCEPTOR
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCESEWER-SANITARY-STORM EA 70ml' Date Revel tlif
Ghlssectlon need not be cwnpldd Lithe permit b forom hundrd dollars
(5100)mr less.) WATER HEALER W/VENT./Pi FCTR ENERGYFEE Y_ N—
I certify that in the performance of the weak for which this permit is baud,
I shall not employ any peraon in any manner so as to become subject to the WA77R SYSTEM/TREATING PAID
Workers'Compensation laws of Callfomb.Dale - '
licant
Z Z N0710ETO APPLICANT•.If,after making this Certifinleof Ezemption,you NEW RFQD77J'DAL I'LMB. SQFT. Date Recei t#
O should became subject to the Workers' proWions oft he Labor TOTAL:
N Code,you must forthwith comply with such providom or this permit shall be BUILDING FEE
W j deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a .Ihereby affirm TOTAL:
that lherebta
acoaction lendingag.my forth.pr4mmv ELECTRIC FEE eI
7 Z Lenderwork for whkhthb permib IssuedIssued(Se<.3WC.)7,Civ. PLUMBING FEE
00 Zanderss NName
.U. F Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE '
O 1 cedlfythal I have read thisappliatlon ad mate that the above Information
O W Ismrred.Iagree to complywlth all cityand county ordinances and mate laws PERMIT ISSUANCE FEES PAID:
j. 1 relating to building construction,and herebyauthown,Representativesmfthb
H N city to enter upon the above-mentioned property for hopMinn purposes. ALTER OR ADD TO MECH.
? (We)agree to save,Indemnify an d keep harm0ew the City of Cu Perrino Date Recel tM
L) against llabilites,judgments,was and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,00)CFM) SUBTOTAL:
.galatttnnnam City in conaaquuum of the granting d this permit CONSTRUCTION TAX
av ,n AIR HANDLING UNIT(OVER 10,0ISI t oaf/A(ptplicam/Contndor[�/L -�C./�571e D(HAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE -
WllltheappllcantorfuNrebulldingoccvpantstoreorhandlehazardous HEATING UNIT(TO 1(10,000 BM Date Re I
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
Health and Sddy Code Section 'Is)? HEATING UNIT(OVER 100,000 BTU) T
❑ Yn No
W1111he zppliesnl orfulure building accvpanl use equiprrcnt mrdevicn VENTILATION FAN(SINGLE RFSTD) ISSUANCE DATE
whlcheMl hazardous air ronlamiama ae defined by the Bay Area Ak
Quality Marogement District? COMP OHP OR IM off)BTU)
4 Yes n No
have road the haat ous materials requimnwtsUnder Chapter6.95 of BOILER-COMP(OVER 100,000 BTU)
the Coliforms HRshh&Safety Code,Sections 7550125533 and 25534.1 pg p A 8
understand that lithe building don not currently have a tenant,that It b my NEW RESIDEMIAL MECH. .W P SQ
responsibility to notify the occupant of the requirements which must be met i!
prior to Issuance of a Certificate of Occupancy. J '1
u
Owner or authodd agent Data ISSUED BY:
TOTAL:
OFFICE COPY v