23616 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building I'minc,Identification PERMITNO.
Budding Address: ,/1 23616
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wre aes
A DATE
%9W CITYOFCUPERTINO- DING DIVISION r ( /�C�
r. .A/.F urs Na: APPLICATIO / PERMIT —] �(
} � o BUILDINGELECTRICA4 UMBING HANICAL CATEGORY CONTROL
Architect/Fagin r. ,n/ Lk.Na'
Vv QTY ELE I PER 5RE BUILDING PERMIT INFO
Address: PQL?ATISBDAN
LIC NSEDCONTRA OR'SDECW ION
I here actiwrmthmlam lk 3.ftha Btudec l.mWnfCssina 9(mmmmc APPLIANC DENTIA JOB DESCRIPTION
Inlicense 1Section 7000)of d elect.3o(the Busimssand Profealons Cade,and m
Lkw tela, !orae anddfect. P LlanmCbm LInY
Date Contras r
II ARCHI S N 40
�Z n Ersynd yrry Rlaw eh s OV• 000 SQ,FT�H.00R AREA - f/SQ.FT.
Q CO
E (0 Prof.,.wl STGNSE ECTRIG -N
t OWNE -B LDER DECLARATION SPECIAL CIRCUI M ^
ZFo, a herebyaftirmlhatl exempt(romthe Contractor's License Law(a the R
F2 following maw.(Section 7031.5,Business and Professions Code:My city or TEMI',METI72OR POLE INST.
f' countywhkhmquimapert tWwmtmd,alter,lmpmwdemolbh,ormpalr
'S daanystm mpdortalt ib ance,aLwrequlratheappBantforsuchpermltto (pWERDEVICEq . DATE
rN1 V file a signed statement that he Is licensed pursuant to the provisions of the -
t. Contractors License Law(Clupter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
SOS xIw3 ofthe Bualnessand PrafemlonsCode)orthat he b exempt therefomand TI
the bash for the alleged exemption. Any violation of Section MIS by any
0
applicant fora permit subjects,the applicant to a civil penalty of not morethan OVILE75SWITCFLESFTX'HIRFS
A Ovhundred dollars($SM. NEW RESIDENTIAL ELECTR SQ.RC. STORIES - TYPE CONSTRUCTION
�n I,as owner of the property,or my employees with wages as their sole
compensation,will do the work and the structure is not intended or offered for
Om1e(Sec.7011,Buaimeaand Professions Cade:The Contractors License Law
p'j $ does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP RES.UNITS
RR whodowsuchworkhlmselforthrough Msown employees,provided that such
Improvements are not Intended orof(ered forsale.If,howerver,thebulkiingor
Improvement bsold wlthlnowyearofcompletiaktheowner-bu0derwill have
tllOkurden of proving that he did not build or bnprove fee purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
U L as owner of the property,am exclusively contacting with licensed PERMIT ISSUANCEcontractors to construct the pmjecl(Sec.7041,Business and Profession,Code:
The Contractor.License Law dors not apply to an owner of property who ALTER-DRAIN&VENT-WAIIIt(EA)
builds or Improves thereon,and who carom for such projects with a ass� FEE SUMMARY
c7V&or(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
L_f I am exempt under Sea R&P C for this reason � -
Owner Data
l DRAINS-FLOOR ROOF,AREA, ND. �� SANITARY N
RECEIPTIf
WORK MAN COMPENSATION DECLARATION pp(.nJftFS I'ER TRAP SCIi00L TAX Y_ N_
❑I hereby affirmorken that I have o certula c of aomnt to Dpytheure,(Sa RECEEVr N
ani(lateofWorken'Compensation[wurana oraartifled copythereot(Sec. GAS EA.SYSTEM-]INC.40UTLBTS PARK FEE Y N
3500,Lab CJ
Poiky It GAS FA.SYSTEMAVER4(FA) RECEIPT N
Campanv— y BUILDING DIVISION FEES
❑cptIII copy b hereby furnished. GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECK FEE, �2Zq
witted copy Is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRE'A'SE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 2(IOPT Date Recei t#
(Thismdlonneednotbecompleted Bthepe nit Isfor one hundred dollars
(f10I)wla..) WAIIIi HEATER W/VENT/ELECTR ENERGY FEE Y N 10
I certifyW
that In the performance of the work for which this permit 1. iled,
I shall not empby any person In any manner so as to beconr subject to the WATER y-I.S-T�/TREATING
Workers'Compensation Laws of CaWamla.Data PAID
O Z ApplicantNEWRESIDENTIAL PLMO. SOFT. Date Recel t#
Z 0 NOTICE TO APPLICANT If,after making thin Certificate of Exemption,you
Fshould become subject to the Workers'Compensation provisions of the Labor TOT
N
Code,you=at forthwith comply with such provisions or this permit shall be
CC j deemed revoked. - BUiLDING
FEE Lrbjo,
IL CONSTRUCTION LENDING AGENCY SEISMIC FEE
Thereby affirm that there is a cowtmalon lading agency for the perform A ELECTRIC FEE
0 Z ance of the workfarwhlch this permit is Issued(Sec.3097,Civ.C.)
li O O Lender.Name PLUMBING FE
U. 1- Lender.Addreae QTY. MECHANICAL PERMIT FEE MECHANICAL FEE d'ex
OW Rami(ythatlhavereadthb.ppliatlo..Mstatsthatthe above In formation r
1 Iscomd.I agree to comply with all city and county oHire cee and state laws PERMIT ISSUANCE FEES PAID:
r reiatingtn bulldlngconstrudketicol h.mbyauthosize reprawtatNesofthb
I— (A city to enter upon the above-mentioned property for Inspection purpams. ALTER OR ADD TO MECH.
? save,Indwwi%an d arexem the City of Cupertino Date Recei t#
V agaWtliab abande enm whlchmaylnanywayaccme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
a aiwtsai In on oft a antis ofthlspermit.
a7 AIR HANDLING UNIT(OVER 10,f30CFM) CONSTRUCTION TAX
5 tureaf App iont r Dte EXHAUSTHOOD(WIDUCT) - CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfutum building occupant store or handle hazardous HEATING UNIT(TO 100,0D0 BM Date Rec f
Voterbl as defined by the Cupertino Municipal Code,Chapter 9.14,and the
Health and Safety Cade Section 7S534(a)? HEATING UNIT(OVER lOQ000 BTU) TO Y
ELI
No
WIII thezppliant Rtum building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which next hazardous air contamiwna as cie0md by tM Bay Area Ab -
@+alityManagement Dietrict? BOILER-COMP OHP OR IM,=BTU)
Y:a MN. PAID
Pal 4have read the bazaidowmaterials requirements uederChapter 6.95of BOILER-COMP(OVER 100,000 BTU)
the California Health&Safety Code,Sections 255055,75533 and 25534.1
understand that if the building does not currently have a tenant,that it is my NEW RM DFNnAL MECH• SQ.FT IMRY 1 5 1992
responsibility to notify the occupant of the mile lramenb
which=at be nM
prbrlo Wuanco ofa Cerll(late of Occopanry. - ,
Y Ur Oka...uev
Owner or aulhadzed agent Data ISSUEDIBY:
I
OFFICE COPY