23295 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PEKMIT NO.
Building Add I:a 72 s �I 23295
LoviaSo, � 4.
G R
re rr e :` � one:
CITY OF CUPERTINO-BUILDING DIVISION
contractor. me: Lk.No: APPLICATION I PERMIT
�f BUILDINC-ELECTRICALPLUMBING.MECHANICAL CATEGORY CONTROL N
Arahltect/ gNeer. Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addmu: a11je
elePERMITISSUANCEBLOU I,L�v PLUMS MUCH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9mmmmc• APPLIANCE&RESIDENfIAL ]OR DESCRIPTION
Ingwlth Section7000)ofDWleion3ofthe B.M..nd fessionsCode,and my
license is In full force and effect. PANELS
Lk.p _
Date Contractor UP TO 2DOAMRS
ARCHITECTS DECLARATION XII-1000 AM h
rr N O I understand my plans shall be used as public records. OVER 1000 AMPS FL f/SQ.pT
{r2r7 od Licensed Professional SIGNS ELECTRICAL to a�//�� UTE R �
6 OWNER-BUILDER DECLARATION ` . s
SPECIAL CIRCUIT/MLSC '
Zt, owing afm.(Secton731.5,BsinesseConiractoieLienee Lay try
following assn.(SectionPurcell
11.S Business and Professionsprove, Code:An tl or
O � TGMP.MEIFROR POLE WST.
F muntywhlre requlreaa issuan ocomtmctiresth Wprovq.ertnuch,ormitto
E
atmcture statempriortoent
Its that
heat,aleorect pursuant to
pro for such of permitto POWER DEVICES
Oµ file a actor.Yceres, t that he t 0cemed pursuant it the tion 70ons of the
v� Con3ofthe LkemeWw(CMpler9(com)orthat with Section gWth(hgNG IDOL ELECTRIC
v thesiobasis fo the alleged
d Professions Any violation f exempt 7WIS by any VALUATION
G the basic for the alleged ex thea. My violation of Section no m re any OUTLETSSWITCHESFTXTURE9
Eyehundfora pertNt%5011. .the applicant too dull penalty of no more than
BF hundred dollen he pr. NEW RESIDENTIAL ELECTS 1,an owner of the property,army employees with wages a their wk SQ'TT' STORES TYPE CONSTRUCTION
ccompensation,will do the work and the structure is not intended or offered for
t
5 9 Q vie(Sec 7044,B.M.sad Professions Code:The Contractors Lim.Law
does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RFS.[)MI5
0. who dote such work himeelforthrough his own employees,provided that -
Improvements are not intended oroffered forsale.If,however,thebullding or TOTAL:
Improvement issold within one yearofcmnplelbn,the owner-bullderwlll have
t Nen of proving that he did not build or improve for purpose ovals.), QTY-j PLUMBING PERMIT FEE FLOOD ZONE APN
L as owner of the property,am exclusively=trading with Ilcenred PERMIT ISSUANCE .—
contractors to construct the project(Ser.7060,Buln
aae and Professions Code:
The Contractors Llmnse Ua don not apply to an owner of property who ALTER-DRAIN Is VENT-WATER(EA)
builds or Improves therms,and who contram for such pwjem with a FEE SUMMARY
cr)BjCactor(s)bceaedpursuant to the Contractors Llan.Law. gpIX F[O T.DENCE
I am exempt under Sec. B&P C for this reason
t
OUTSIDE Pi ES
Avner DRAIN FLOOR RAREA,COND. .� SANITARY Y N
Date RECEBT N
WORIONAN
COMPENSATION DECLARATION FEKTURE SCHOOLTA% Y N
❑I hereby affirm that I have a artt(tcne of consent to sellAnsure,or a RECEIPT N
nrtlflateofWorkers'Comper timlmunnnoraartifk mpythereof(See. GAS FIt.SYS'fFM-1 INCAOUTLkTg PARK FEE Y N_
3800,Lab C.)
lCtillml
CAS-FA.SYS'TEM-OVER{(FA) BUILDIING DIVISION FEES
mlropyVherebytushedGREASE/INDUSIRL WASEINTQ2C0'TOR PLANCHECKFEE
ropy V filed with the city Wpection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRN' PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA.200FT. Date Recai tic
(Thisaedbn need not be completed lithe permit Ia(orom hundred dollar
(f10B)orless.) WATER HEATER W/VEM/FYECTA - ENERGY FEE Y N
I certify that In the performance of the work forwpermitsu
ich this permit is ised, _
I shall not employ any person In any manner n as to become subject to the WATER SYSTEM/TREATING
Wm1x,.Compenation L.wsof QIffornla. Date PAID
O Z Applicant NEW RFS DEN77AL PLMB. SQ.FT. Date Recei ted
Z NOTICETO APPLICANT.If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
1— N Code,you moat forthwith comply with such provisions orthlspemdtshall M BUILDING FEE
j deemed revoked.
dCONSTRUCTION LENDING AGENCY SEI S IC FEE
I herebleafRrmthat there is a construction lendingagency forthe pedorm� T ELECTRIC FEE
Z ane of the work for which this permitla luued(Sec 3097,Civ.C.)
00 I.andres Name PLUMBING FEE
LL F Lender.Addreas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW IartitythatlhavereadthbapptloBonanddatethattheabovelnformation
a Ismrrect.I agree to complywlth all cityand county ordinances and Yate laws PERMIT ISSUANCE FEES PAID:
rrelating tobullding construction,and hereby authorize representatives ofthls
N
H Z city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH.V DRIB Receipt#— (We)agree to save,Indemnify an d keep harmless the City of Cupertino
agaWtBab Itle,pdgmsnte, sandexpenxa ichmeylnanywayac a AIR HANDLING UNIT CT010,000CFM) SUBTOTAL:
against d .itylmm;xq oft granting of this permit. AIRFANDLINGUNTT(OVERI0,000CIM) CONSTRUCTION TAX
SIg . Ap rat/ ontra � ��� D(FIAUSTHOODlid'/DUCT) CONSTRUCTION TAX PAID:
TAZARDOUS MATERIALS DISCLOSURE
ill the applicant or future building occupant store or handle hazardous HEATING UNIT(TO IMODO BTU) Date Recei tM
materialnd dean d by the coon 2 5 Munidpal Code,Chapter 9.q and the
Health and Sat/sty Code Section 75532(a)7 HEATING IJMT(OVER 100,000 BTU) TOT
0 Yes , No
Wiilthezpplkant a lure building omupant use equipment ordevims VFNDLATION FAN(SINGLE RESID) ISSUANCE DATE
which eMl hawrdoua ak mntamlnanle ae defined by tM Bay Area Alr
Quality Management Di❑❑strIct7 BOILER-COMP phm OR I00,00D BTU) p�
No
i have read the haxa us materials rrquhremerts under Chapter 6.95 of BOILER.COMP(OVER 100,000 BTU) P A 0
/ the California Health&Safety Code,Sections 75505,25533 and 25536. 1
understand that if the building does not currently have a tenant.that RIs my NEW RESIDENTIAL MEC71. SQ.FT FEBrespamibWty to notify the occupant of the requWments which must be and prior +0 1992
prior to Issuance of a Certificate of Occopa nry.
Owner or authorized agent Date ISSUE },R^ 11
TOTAL:
OFFICE COPY