23494 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — LL POINT PEN ONLY
Building Prreel Identification PERMITNO.
Building Address: 23494
lRcit Cosi-;� A L
ams: one: -
% 1 24
—&R44 CITY OF CUPERTINO-BUILDING DIVISION '
contr.itor. eros: Lie.N.: APPLICATION / PERMITAffilk
5`� BUILDINGELECTMCALPLUMBINGMFCHANICAL CATEGORY CONTROL p ,�"•
Arehltect/Eegtrreer. Lit No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION of Chapter
I behScctkaffirm 0)ofDivBcenaedunder provWwsof ChionsCommmenc- APPLIANCES-RESIDENTIAL JOB DESCRIPTION
in&wftIt...h ].full force end sed. ofthe Businemsnd ProfnsiomCnde,end my ���
It...Is in full farm and died. PANELS
Limn.Clam Lk.N
Date CmdracmrUP TO 2DOAMPS -M Cc 169ACX-,
ARCHITECI•S DECLARATION 101-1000 AMPS
no O I understand my Plana shall be used as public records OVER I0D AMI'5 SQ.FT.FLOOR AREA N/SQ.FT.
M 'Licensed Professional SIGNSELECTWCA
{� $ 1QaOO
�< OWNER-BUILDER DECLARATION SPECIALCItCUIT/ TSC tV ,_
Zs' 4 Iherebya(flmnthatLmezempt(romlhe C°ntraRore License Lew(orthe
following remon.(Section 703]5,Business and Profemlons Code:Any city or K
F,�t' coantywhlch requlresa permktomeatvtt,alter,impmvq demolish,errepair TPMP.MEFER OR I
8 anyatr mpe"tolbb ame,aLwiqulmtheappH..tfersuchpermitto POWER DEVICES
(� file a signed statement that he is Emoted pursuant to the provisions of the — DATE
SO ti Contractors License law(Chapter 9(commencing with Section 7000)of Divi- VAJiUAI70N
OS xkm3ot NeBudmed.cd ProfembnsCode)orthat he la exempt therefromand SWIdMING PQOL ELECTRIC vG
the bead for the alleged exemption. Any violation of Section 70315 by any 1;
appacant fora permitsubjectslheappli...tWadvllpenaltyofnrtmorethan OU'17-E7SSN71CHESFI%NRF"' {BOO
live 1,as
owndoler
of thepr. NEW RESIDENTIAL Gr ECTR SQFr STORIES TYPECONSIRUCTION
�n ❑I,ac owner of the property,or my employees with wage se their sole
< mmpceadion,willdothe work andthe structure Is not intended or offered for
O .1.(So.70K Budrasa ami professions Code:The Contractors Llmnae law
�$s clan not apply to M owmr of property who Wilde or improved thereon,and OCC.GROIJIs AFS.UNITS
Improvements
doedsuch work himaeBorthrough Ne own employees,provided that such
Improvements am not Intended oraffered for sale.If,however thebulldleg or TOTAL:
Improvement lasold withinoneyearefcumple lon,theownerbuilderwill have
'p tlP�umen of proving that he did not build or improve for purpose°lsale.). QTY. PLUMBING PERMIT FEE FLOOD 7ANE APN
o of I,as owner of the property,am exclusively..batting with licensed PERMIT ISSUANCE
c tractors to construct the project(Sec.7044,Business and Profeadoes Code:
The Contractor'•License Taw don net apply to an owner of property who ALTER-DRAIN Is -WATER(EA)
Wilds or Improved thermos,and who contracts for such ptrjects with a FEE SUMMARY
<yl(Ia6 a)licensed pursuant to the Contractors License Law, BACK FLOW PROTECT.DEVICE
LI I-am exempt under Sea B&P C for this reason
i$00,el'.b
OUTSI Dy FEES
DRAINS FLOOR ROOF,AREA,C'OND. SANITARY Y N_ -
® DMe AFLEI'T p
WORKMAN COMPENSATION DECLARATION FD(TURE4�PER TRM SCHOOL TAX Y_ N
I hereby affirceWorkers'
that I have o Insurance
nsuraa c o cement to op thereof
ora RFGEIP1'p
Bcaa of Woricers'Comperuationlmunnceeraarti(bd copytheresf(Sec. GAS EA.SYSTEM-1 INC<OUTLETS PARK FEE Y N
CJ
Pdlry N RFLEII'1'p
CAS EA.SYSTEM.OVER 4(FA)
Com any BUILDING DIVISION FEES
MCertlOed copy In hereby furnished. GREASE/INDUMRL WASTE INTERCEPTOR PLANCHECKFEE
MCertNed ropy la toed withh the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-gANTTARY-STORM EA.]WF7. Date RCCCI t#
RMssMlon need
no becompleted If the pmmlt la forom hundred dollars
(S10a.rind.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certifythat In the performance ofthework forwhlch this permit Is hued,
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workers Compensation Lives of Ca1Bomia.Date PAID
Z 0 NOplicant TICE TO APPLICANT:If,after making thlsCertlllmte of Exemption,you NEW RFc1DENTIAL PLMB, SQFf. Dale Recei t#
should become subje t w the Wmiumi'Compematbn provisions of the Labor. TOTAL:
N Code,you mu at forthwith comply with such provlabm orthb permit shall be I 4
W > deemed revoked. '
EE
0. CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby afflrmthat there la a construction lending agency for the perform ELECTRIC FEE
7 Z ante of the work for which this permit la isamd(Sec.3X97,Civ.C.) TOTAL:
O O Lenders Name PLUMBING FEE
IL I— Lundee.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW IcertltythatIhave readthlaapplicathm.nd date that theabove Information
1 bmrrect.Iagreeto.° plywhalltltyandcounlyerdlnanmand Mato].. PERMIT ISSUANCE FEES PAID.
N reIattngi.b.ilding.mtmaim,a^dhembyauthorimmpmentntigaofthis
1... U) city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMFCH. Date ReCel t#
(We)agree to savem
,indenify an d keep harmless the City of Cupertino
V thabli[les,jidg rents, sand expenses which may In anywayacmue AIR HANDLING UNIT(TO I0,0D0 CFM) SUBTOTAL:
ages acid ity In con ^ting spermlt AIR HANDLING UNIT(OVER IQ000CFM) CONSTRUCTION TAX
S, na
of Ap Ile nt/ ontractor Data EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appllcant mN
fore building occupant store or hand le hazardous HEATING UNIT(TO 100,000 BTU)
material.. Date RCCei f#
deflred by the Cupertino Municipal Code,Chapter 9.11,and the
Ilealth and Safety Code Section 25531(a)7 HEATING UNIT(OVER 100,000 BT(I) TOTAL:
❑Yes MN.
f Will the applicant or future building occupant use equlpennt or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as deRmd by the Bay Area Ab
Q+ Ilty Masagesrnt District? BOILER-COMP DEEP OR IW,000 BTT]) p '
Yrs �No MY
ve read Health
a Tet mode, ection)25505, 5533underChapter 6.95 of BOILER-COMP(OVER 10D,000 BTU)
the CaliforniatandtHealth&Safety Code,Sections25505,25533have
a tend,that
APR 7 -
usponsindthatIf the netifyteoccupading nnote currently haves[stemthat b lamy NEW RESIDENTIALMECIi. SQFT
responsibility to Issue ce of lty the campers[of the requirements which rrwrt be met
prior to Issuance car a Certificate of Oavpanry. ClI Y
�fv�L I�/IA�yC.('1111Y
Owner or authmlved agent Date TOTAL: ISSUEDBYVV"� I ,
OFFICE COPY.