23868 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Add ran: OdOZ E)F A- PoW D 23868
Ph one:
/,2 CITY OF CUPERTINO-BUILDING DIVISION /y
c •Name: Lle.N. APPLICATION /PERMIT
BUILDINGELECTRICAI PLIIMBING-MECHAMCAL CATEGORY CONTROL M
Architect/Engineer: Lice.No:
- QTY ELECTRIC PE MIT FEE BUILDING PERMIT INFO
Addms:
KLDG
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION PERMITANCE "oses
Thereby
affirm that
ensed under provisions ofChapmr9(mmandmme-yInMfun700fDIA.i3oftheausinandPmfWonsCode,
license Isintub force and effect.
let.# PA
So,
J BDESCRB'fION -
.,
Dale Cmd ach,
ARCHITECPS DECLARATION 201'1
t, aO Zp I understand my plane shall he used as public mounds. OVER OX)AMP'
RAREA S/SQ.FT.
Lfmnscd Pro?.—WRal SIG NS ELECTRICAL F IVI R
OWNER-BUILDER DECLARATION SPP.CIALCIRCWT/MLSC DAT
2: �z thereby affirm that l am exempt from the Contractor's License Law for the
QQ following reason.Igraine 70115,Business and Profession Code:Any city or
Cf' aruntywhich requboa permit tomnstmct,alter,Improve,demobsh,orrepair iFMP.MET020R POLE INST.
q� anystmc mprlortoltisauancealsomqulmtheappBantfamchpermitto
P O TOWER DEVILS
Rle a signed statement that he is Demandband pursuant to the provisions of the
036';O Conlranots License Law(Che plate m
r9(mmmetingwlthSeM1anMeatofDlvi-
u' SWIMMING POOL ELECTRIC slon3of the Businedsand Pm(embruCode)orihat het exempttherefromand ' /a^ VALUATION
O 5 the basis for the alleged exemption. Any violation of Section 7015 by any OUTLETSSWITCHESFIXTURES •''(!`` .A'�1�'
applicant for a permit subjects the applicant to a civil penalty of net more than f v 1 V V
five hundred delta.(MM. SQ. STORIES TYPE CON57RI1C770N
�n
F11,ac owner of the property,or my employees with wages r offered
dole
NEW RESIDENTIAL ELECTR FT.
C .1.(Sedat0K B.ldotheworrf.1he etmcte:TheCintended n'o License
Law
5a O dale(Sec.7044,Business and f property
Code:The C improves
Wmve law
q R whodossuch[oanownerofpmpghhisobuilds nemporlmproovidedthatand -ruch OCC.GROUP RES UNITS
w whodoementsa orkhimdelf edreofgh Msowne.If,ho es,however,
provided ing or
Improvementarenet Intended earofco for sate.theower-1 dider ldidgve T
Improvementtmldwithinoneycara(complMloM Iheawner-buliderwBl love
.th;;- rden of proving that he did net Wild or Improve for purpose olsale.). QTY, PLUMBING PERMIT FEE FLOOD 7DNE APN
LJ I,as owner of the property,am exclusively contracting with limned PERMIT DANCE
contractors to construct the pmject(Sec.7044,Business and Professions Code:
The Contractor's Limn Law does not apply to an owner of property who
WildsALM-DRAIN&VENT-WATER ffA)
or Improves therms,and who contracts for such plofec s with a
egRI(aMarta Bmnd pursuant to the Contractor's License Law. FEE SUMMARY
(_JI am exempt under See. B&P C for this..a BACK FLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,CONI. SANITARY Y_ N_
Owner Date RECEIVE If
WORIOHAN COMPENSATION DECLARATION FpfIVRFS I'ER TRAP SD30OL TAX Y_ N
pI hereby affirm that I have a comflate of consent to self-Insure,or
mrtlfiamof WorkeW CompenaHon Insurance a a msifted copythermf(Sec. RECEI'f Y
3g00,lAbCJ GAS EA.SYSTEM-1 INC40IEIT,EIS PARK FEE Y N_
Policy 4 RECEIPT M
Csrt�i any - GAS- BUILDING DIVISION FEES
I ICenlfled mpybhereby/umlMed. S FAFREP'T'OR PLANCHECK FEE
LFJi Certified copy Is GREASE/WDUSIRL WASTE INTERC
filed with the city Inspection division. L/ 6
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFA-SETRAP PAID
COMPENSATION INSURANCE SLAYER-SANITARY-STORM EA 203Ff Date Recei [#
(ThisseMlon need nM be completed Ithe permit bfa ons hundred dollars
($10D)crlem.) WATER HEATER W/VENT/ELRCTR ENERGYFEE Y N—
I certifythat In the performance of the work forwhIch his permit is blued,
I shall not employ any person in any manner seas to become subjectto the WATER SYSTEM/TREATING
Workers Compenatbn Laws of Callorn(a.Data PAID
O Z Applicant NEW RESIDENTIAL PCMB. SQFf. Date Recei t#
Z O NOTICETO APPLICANT:If, nuking uking this Certlflaleof Baemptbn,you
Fshould become subject to the Workers''Compenatlon provisions of the Labor TOTAL:
— Code,you=atfort hwlth comply with such provtmi
lon or this pert shall be BUILDING
W > deemed revoked.
low—
CL G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby afflrtnthat there is a construction lending agency for lhepeAorm TOTAL: ELECTRIC FEE
M Z arm of the workforwhlch this permit is heated(Sec.3097,Civ.CJ ELECTRIC FEE
lender's Name
LL LL H Lenders Addrese QTY. MECHANICAL PERMIT FEE
O W Imrllythat l have read this application and statethaltheabovelnfornalon MECHANICAL FEE
S tcomet.lagreeto comply withal)city and countyordlnanms and state laws PERMIT ISSUANCE FEES PAID:
�. reIti.gt.b.ilding mntruMlon,and Mrby authorfes reprrsentativesoftht
(— IA Miytoenterupon the above-mentioned property fort petionpurposes. ALTER OR ADD TO MECH.
Z Date Receipt#
_ (We)ages to cove, demNty and p mw the City ywaya Cupertino -
agalmtb b ties,' d nts,yaAand nsedw nuy In any wayacerue AIR}LpNDllNC UNIT 8010,000 CFM) SUBTOTAL:
against CB naary oft gramin his L
AIR FIANDWNG UNIT(OVER 10,030CFM) CONSTRUCTION TAX
SI reol Appba /Contnctor .. Date IXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
N 2ARDOUS MATERIALS DISCLOSURE
WllltheappB or future building occupant store or handle hazardous HEATING UNIT(TO 100,0DO BTU)
material as deft Wythe Cupertino Munlcipa l Code,Chapter 9.12,and the Date R ei t
Health and Safety Codlee Srl
eaton n25532(a)? HEATING UNIT(OVER 100,030 BTW T
RY.
ill he applicant or future building oavpant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit harardous air contaminants as defined by the Bay Area Air
silty Management District? BOILER-COMP DHPOR 100,000 BTW PAID pi
�u�I Yes ❑No A 1 D
I have read the hazardous materials requirement under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
4 the Ca)Ifornfa tlealth&Safay Code,Sea tons 25505,75533 and 25534.1 AUG 1
undenta Rd that lflhoWildleg does not currently have a tenant that It is my NEW RESIDENTIAL MECH. SQ.Fr. AA4�
responsibility to really the occupant of the requirements which moat be met .•77vJ7G
prlortoimuanofa CertiflcateofOa pancy. VY
Cn i inU
Owner or authodud agent Date
TOTAL: 1SSUEDBY:
OFFICE COPY