23504APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT AN ONLY
Building Project Identification
Building Add. ss:23504
o Prv�
PERMITNO.
ane:APPUCATIONSUBMITTALDAIL
CITY OF CUPERTINO-11U TNG [VISION
APPLICATION[ MIT
BUILDINGELECTRICA' I C- HANICAL
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CATEGORY VIS
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ArcMtett/Engineer. Lk. Nm
QTY ELE M
FEE
BUILDING PERMIT INFO
11
Address:
PERMITISSU
�j ❑ a .
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions ofChapler9 (mmmen
If...iSection7000)of DlWect. flhe Businessand ProlesslansCade,an
Llcr. lslMa roe and rices.
Date sss Lica
Date Gm
RE9DE
JOB DESCRIPTION
e1ef
201-1
ITECT
ARCHITECT'S DECLARATION
l understand my plansMall beused n public records.
LkensedProfessioml
OVER
SQ. FT. Il.00R AREA
�� 41
S/SQ.FT-
SIGNS L CA
5]'ECIALCDt T/MIST
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
TEMP.OR POLE [NST.
following manner. (Section 7031.5, Business and Professions Code: Any city or
county which requires permit to construct, alter, Improve, demolish, or repair
anyatructure prior to Its Issuance, also requires the applicant for such permit to
file a signed statement that he s licensed pursuant to the provisions of the
fO DEVICES
NG POOL ELECTRIC
UTL
OEISSWITCHESFIXTURFS
Conrseter'sL+cerise Law (Chapter 9(commencing with Section 7000) of Divi.
sion 3 of the Business and Professions Code) or that he b exempt therefrom and
the basis fur the alleged exemption. Any violation of Se tion 7031S by an
appliontfora perMteubje 4lheapplkanttoa civil perultyor not more than
VALUAlIQ(fpa
CN
O I f
NEW RESIDENTIAL ELECIR SQ'R'
five hundred dollars (SM.
❑I, as owner of the property, or my employees with wages as their sale
compensation, will do the work, and the structure cram intended or offered for
.Is (sac. 7044, Business and Pr fesslam Code: The Contractor's Llceose Law
STORIES ,
TYPE CONSTRUCTION
4 A
T
does
oeapply torn owner ofproperty who
who daemsuch nemparlmprrovidethatown themes, and
Msowne.If,ho evert ebuilatuch
ntsa.a intended
Improvamentarenot Intended orrof for.ak.ILhowever,fldcrldingve
pC�GR I,Br RES UNITS
' LnV' A p N
improvement ssold that cam
proving id nm Wild orlon,theownar-bu0derwIDlove
tIISj Las o neerof the p o e+d nmWild orvely contracting sox orukJ.
LI L as owner of the property, am exclusively Busi mntnct+ng with licensed
contnton to mmW ci the project (Sec.7014, Businessend Professiam Code:
QTY. PLUMBING PERMIT FEE
R
PERMIT ISSUANCE
The Contnto's License Law does not apply to an owner a property who
builds or improves thruster, and who comment for such pCojets with a
ALTER DRAW k VENT WATER �)
BACK FLOW PROTECT. DEVICE
cgla(+tote) Bmmed pursuant to the Contntors License Law.
LJ I am exempt under Sm B h P C for this reasonOUTS
I DE FE ES
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y N_
RECEIPT I
Owner Data
WORKMAN COMPENSATION DECLARATION
I hereby affirm that I have a mrtifferm of canxat to self -Inure, ce a
FIXTURES PER TRAP
SCHOOL TAX Y N
RFCEIT N
GAS EA. SYSTEM -1 WC.4OUTLETS
PARK FEE Y N
RECEIPT#
ce finte of Worken'Compm
eationlmm uranoracutified copy thermf(See.
3800, lab C.
Policy '}al6—OL
if
om any .v+e7n 1'
Cd.
GAS EA.SYSl77d-0VER4(EA)
BUILDING DIVISION FEES
CertBl copy s hedwith tthe city
Certified copy s hereby f ref hetylmpMion division.
GREASE/WDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE Ly oig
—! 1.
GREASETRAP
CERTIFICATE OF EXEMPT ION FROM WORKERS'
PAID
SEWFRSAMTARY-SR7RM EA20lDate
COMPENSATION INSURANCE
(fhissectlon need not be compieted lithe permit sfor one hundred dollars
Recd tM
WATER HEATER W/VENT/EIRCTR
ENERGYFEE Y_ N_
($10))orlass.I
I unity that in the performance of the work forwhlch this permit is sued,
WATER SYSTEM/TREATING
I shat+ not employ any person in any manner so as to became ublect to the
Workers'Compensstlon Lawn of California. Date
PAID
NEW RESIDENTIALPLMB. SQFT.
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Workers' Compensation provisions of the Labor
Date Recei til
TOTAL:
U IN
Cods, you at forthwith comply with such provisions or this permits hell be
deerrad revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE a. qzn
Ihambyaffirm that them us comlrutlon lending agency for the perform-
anm of the work far which this permit s sued (Sec 3097, Civ. CJ
Lea l.e. Name
Landresadd.
I mrtlfythat I have readthsapplintionand natethatthe above Information
iscooatt. I agreetocomplywlthallcityand countyordlnanmsand statelaws
TOTAL:
ELECTRIC FEE
77271
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating to building comtution, and hereby authorise representatives of this
city to enter upon the above-mentioned property for Inspection purports,
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
aga+mt+labilltkq' dganent cone ande.peneeswhkherayinenywayacaue
Date ReceI til
ALTER OR ADD TO MECH.
AIR HANDLING UNIT CrO 10,000C IvO
SUBTOTAL:
agalmtard City, consaryenoeorthsgnntingathl•permit.
.
V
AIRHANDUNG UNIT (OVER 10,00.CFM)
CONSTRUCTION TAX
EXHAUST HOOD(W/DICT)
CONSTRUCTION TAX PAID:
qj--
igmture of Applicant/Contractor ate
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant more or handle lueardous
Date Recel tN
HEATING UNIT (TO 100,000 BTU)
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Health and Safety Code Section 25532(.)7
qYes u No
llltheapplicant or Iona. building oavpart useequipment ordevim
HEATING UNIT (OVER 10°,030 BTI[)
� -TOTA
DATE
VENTILATION FAN (SINGLE RFSID)
which emit harardoair contamnts as defined bythe Bay Area Air
m rru
Q1vMRy Management District?
W's No
4havemad the h.Y.us materials requirements under Chapter 6.95of
�ISSUANGE
(f� 11 1U`
18 1992
BOILER -COMP OHPOR 100,000 BTU)
BOILER-COMP(OVER 100,000 BTU)
the California Health k Safety Code, Sections 25505, 25533 and 25534. I
understand that if the building does not currently have a tenant, that It Is my
respomtblbty to notify the occupant of the requirements which most be met
prior to issuance a aoccupantCITY
Certificate of Occupancy.
spy .
Uf CuptTiI INU.n^/
O2
ISSUED BP
NEW RESIDENTIAL MECH. SQ.FT.
-
Owner or authorised agent Date
TOTAL:
OFFICE COPY