23567 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALLPOINT PEN ONLY
Building Project Identification I PERMT NO.
Building Address: 235^r 6 7
e c tl(l
ante: one: A
CITY OF CUPERTINO-BUILDING DIVISION "2
canto Aur. ante: ue.Na: APPLICATION I PERMIT L
BUILDINGELBCTMCALPLUMBINGMECHANICAL CATEGORY CONTROL N
rehitActlEAgilkeen Lk.N.
QTY ELECTRICPERMIT FEE BUILDING PERMITINFO
Address: PFRhITI55UANCE ❑. ❑ ❑ -
LICENSEDCONTRACFOR'S DECLARATION
I hereby affirm that l am licensed under provisions o(Chapterg(commem, APPLIANCES—RESIDENTIAL TOB DESCRIPTION
Ingwlth Sectiun7DOO)of Divlsion3ofthe B.s.essand Pmf.n..Codg and my
Brenn is In B( affect. c PANES
Lkenn Cl�.g_
Date /�1T.r-T� _ContraRar UP TO'DAMP'
ARCHITECT'S ECLARATI 211-IODDAMPS
2 I understand my plana shallbe used w public record.. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
z� Licensed Professional SIGNSELECTRICAL r
6 ' OWNER-BUILDER DECLARATION Ir In I A
] SPECIAL CIRCUIT/MISC i, i`.,/ ,v
7 l'• Iherebya(flrmthatiam exempt the Contractor License Lw for the
pp fogowingresson.(Section 7031.5,Badness and Professions Code:Any city or
�2Hggq TFMP.MEIIROR POLE IN ST. '
� cmntywhlchnquiresaperrdttomlutnc"ter,impmwderoWh,arrepair �., 1'.
qqq anyst =mpdortoita Lwuame,alsorequlmlheapphmtforsuchper tlo POWER DEVICES
h"JI \.i' E
file a signed statement that he Is licensed pursuant to the provisions of the
3µ(- Contnctori License IA.(Cbepter9(commencing with Section 7000)of Diel- SWIMMINGPOOL ELECTRI DAT AL TION
OJ don3afthe Ruslnmmd ProfembmCode)orthathebemmptthemfmmand
'�a.•77 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWIICHFSFTXTURES
applicant for a permit subjecoathe applicant to a civil penalty ofno more than
five hundred dollars elM. NEWRESIDENTIALELFf_TR SQ.FI. STORIES TYPE CONSTRUCTION
❑I,as owner of the property,or my employees with wages as their sole
mmpenntion,willdothe work andlhestructure Is not Intended or offered for
Auto llw,70K Business and Professions Code:The Contractors License Law
�$ does not apply to an owner of property who Wilds or improves thereon,and OCC.CROUP RES.UNITS
EE whodon such work MmseUmthrough his own employees,provided that such
Improvements are not Intended oroffered for sale.If,however,the building or TOTAL:
improvement bsold wlthln oneyearufcompleiom the inner-buDderwlll have
tl&,urden of proving that he did not bold or Improve for purpose ofnbJ. QTY. PLUM BING PERMIT FEE FLOOD ZONE APN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to coretroct the project(Sec 7096,Business and Professions Code:
The Coamctoes License Law does nor apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
builds or Improves thereon,and who contracts for such p0op -
cts with a FEE SUMMARY
gB�(actor(.)Rcen.ed pursuant to the Contractor.Lt..Law.
c LJ 1 am exempt under gee B k P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
• Owner Date _ RECEIT M
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y_ N
❑I hereby affirm that I have o Insurance
of consent m set&Insure,ora - RECEPT a
cedlflcateofWorken Compensation Insurance ora certified copy thereof(Sec. GAS PA.SYSTEM-1 INC.6 OUTLETS PARK FEE Y N
Polic Lb CJ RECEIPT'R
Pollryap�� GAS EA.SYSTEM.OVER 4(EA)
Com nv /A BUILOINC DIVISION Fr.ES
[PCertNed copy Is filed
thehid. GREASE/INDUSI'RL WASTE INTERCEPTOR PLANCHECKFEE
Lj
Certified copy b flied with the city Irapection division.
CERTIFICATE OF UMPIION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA XIOFI Date Rewi t#
(Thlssectlou need not becompleted lithe permit h froom hundred dollars
($I00)orlm.) WATER BEATER W/VENT/ELECTR ENERGY FEE Y - N
Ins ifythat in the performance ofthe work forwhich this permit is issued,
I shall not employ any person In any manner An as to become subject to the WATER SYSTEM/TREATING Workers'Compensation Laws of California. Date PAID
-
0 Z NOTICApplicE
cat NEW RESIDENTIAL PLMB. SQJ.7. Date Receipt
2 O NODCETO MPLICANTIf,.aer rs'Co persat[onhis Ipro is Exemption,you
should become subject to the Workers'Comperaatlon provlslrre of the Lebon TOTAL:
N Code,you=at forthwith comply wlthsuch provisions mthis permit shall be BUILDING FEE
W j deemed revoked. ,
CL C CONSTRUCTION LENDING AGENCY SEISMIC FEE
Ihercbyaffirmthat there bacnnnuctlon lending agency for the perform. TOTAL: ELECTRIC FEE
M O anceoflheworkfor which this permit is tamA,f(Sse.3097,Civ.C.)
Lender'.Name PLUMBING FEE
LL F Lendee.Address QTY.I MECHANICAL PERMIT FEE MECHANICAL FEE i
O W n
Irerlifythat I havereadthis applcalionand slalethatthe above Information
CL Is coret[agree to comply with all city and county ordinances and state lawn PERMITISSUANCE FEES PAID:
} N relating is building construction,and hereby authorize representatives ofthis
F" Z city to O enter upon the abovcmentlorud property for Inspection purpose. ALTERORADDTOMECH. Date ReCfIPI#— (We)agree to save,'Indemnify an d keep harmless the City of Cupertino
a
fixing liabilities,judgments,coRsand expenses which may N anywayaatue AIR HANDLING UNIT(T010,000 CFM) SUBTOTAL:
tyro nsequen he gnntln of this permit AIR HANDLING UNIT(OVER I0,000CIM) CONSTRUCTION TAX
�I
Igwtp fApplican C raci� � Data EXHAUST
EXHAUSTAUST HOOD(W/D(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfutum building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date R t#
material as defined by the Cupertino Municipal Code,Chapter 9.I$and the
I health and Safety CodeSection25532(a)7
HEATING UNIT(OVER 100,000 Bi1A TOT
❑ Yea . (T No
Will the applicant ur lure building occupant use equipment or devim VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hazardous air contamimnts as de0med by the Bay Area Air
Quality Management District? BOILER-COMP OTE'OR 100,000 BTU)
Yea 2%
Thavcread the hazardous materials requImmentsunder Chapter 6.95of BOILER-COMP(OVER 100,000 BTU) B p�
the California health k Safety Code,Sections 25505,25533 and 15534.I - D
understand that lithe building does not currently hivA.tc...I,that it is my NEWRESIDENTIALMECH. SQFr
prior lbl fa the occupant of the requirements which mwstberret ITEC 4 19,
msp nsibili race o(a theca eo(Oc ry. L..II//
CII . ,
mer or out a n Date
TOTAL: ISSUED BY: I IV
OFFICE COPY