23555 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
-Building Project Identification - PERMIT NO.
Building Address: 23555
la � �Iv
11 nerd ante: one: A
CITY OF CUPERTINO6BUILDING DIVISION
Cont ctor's Ic.No: APPLICATION It PERMIT ut •7-
CATEGORY CONTROL#
! Arehited/Engf ri Lic.No: ,
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ 1:1 ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that am licensed under pro,blonsof Chapter9(commene- APPLIANCESRESIDENTIAL JOB DFSC)PMON
IngwithSeatlon7000)ofDivision3oftheBusimmandProfesstonsCode,and myPATES0
/Ga'rp'r µ�.s./��
license fe ln'�ect. �S UP TO21�C1►�.1'P GJL
Limn m # J
Data .ntracior
ARCHITECTS DECLARATION 201-1000AMIP5
q�q�uu NCOC I understand my plsru ahallbe used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA 1/SQ.FT..
cz o U Licensed Professional SIGNS ELECTRICAL - s
<6 OWNER-BUILDER DECLARATION "
Ci SPECIAL CIRC[BT/M15C
I hereby zF
following reason,
I ant,7031 Z, tiro ,theossa d Professions Code:or's License Law!othe
following reason.(Section 70015,Business and Professions Code:Any city or
Ff'u9 county which requires a permit to mrutruct,alter,Improve,demolish,or repair TEMP.METERORPOLE]NST.
a� anystmcture prior to its Issuance,also requires the applicant for such permit to
G file a signed statement that he is licensed pursuant to the provident of the POWER DEVICES_ _ -
Gp/7 0µ Contractor's License Law(Chapter 9(commenting with Section 7000)of DIW-
�0 sion3oftheBuA essand ProfewWmCode)orthatheismmpttherefromand SWIMMING POOL ELECTRIC VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any OIITLETSSW[TCHESF[%TURPS ,
O
applicant fora permit subjectstheapplicauttoa civil penalty done morethan
five hundred dollars(1500).
R NEW RESIDENTIAL ELECTR SQ}T.kFEE
STORIES TYPE CONSTRUCTION
❑L as owner of the property,.r my employees with wages r there wk
compensation,B.g.theworkftedo atruciurelenot Intended Lioffered for
sale(Sec.9044 Bueimss end Profecsloro Cade:The Contraesots License law
3$ doesndapply toanowner of propertywho builds orimprovesthereon,and OCC.GROUP RFS.UNITS
who does such work himself orthrough his own employees,provided that such
bnprovem ob;are not intended oroffered forsale.If,howeaver,thebuilding or TOTAL: -
improvementlssoldwithinoneymrofcompletlomtheowner-bullderwill have
t rdenof pumingthat he did not build orlmprove for purpose ofsaled. QTY, ';"' "PLUMBING PERMIT I�I 4 as owner of the property,am exclusively contracting with licensedFLOOD 7ANE AFN
contractors to construct the project(Sec.7044,Business and Pmfesdons Code: PERMIT ISSUANCE
The Contractor's License Law does net apply to an owner of Property who ALTERDRAIN k VENT WATER(FA) 1
bullds,or Improves thereon, - -
n, and who comment fee such ptojects'with a FEE SUMMARY
,PtfaRar(s)licensed pursuant to the Contractor's License Law. BACK FLOW]PROTECT.DEVICE
u I'am exempt under Sea B k P C for this reason _
OUTSIDE FEES
Owner Date DRAINS FLOOR ROOF,AREA,CONI. SANITARY - Y_ N_
.RECEIPT#
WORKMAN COMPENSATION DECLARATION
❑ FIXTURES.PER TRAP SCHOOL TAX Y N
I hereby affirm that I have a certificate of consent to self-Insure,ore RECEIPT# -
certifimteofWorkereCompematimlr mncemacertifledcopythemof(Sec.
3900,Lab C3 GAS FA. IM INCA OUTLETS PARK FEE Y N_
PoIIryN GAS EA.SYSTBM-OVER4(EA7• RECEIPT#
Com any BUILDING DIVISION FEES
[YCen dcopy,s by(umb e . GREASE/INDU5IRL WASIEIN'1'E[tCEPTDR PLANCHECK FEE
If ed copy b RI d with the ctty Inspection dlvbian.
CERTIFICATE OF EXEMPTION FR OM WORKERS' GREASETRAP 'PAID
COMPENSATION INSURANCE EWER NI'fARY STORM EA 20081• �� Da[e Recei [N
(Th,sse<tion need not be completed if the permit Is for..hundred deltare
($100)or less.) WATER HEATERW/VENT/ELFLTR ENERGY FEE Y N
I certify that In the performance of the work for which this permit Is Issued,
I shall not employ any person In any manner an as to become subject to the WATER SYSTGM/TREATING'
Workem'Compensation Lawaof Glifomla.Date PAID
O Z Applicant NEW RESIDENTIAL PENIS. SQFI. 'Date Remi t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you ,
F,N
should become subject to the Worken'C.mperwtbnpmvblom ofthe Labor - TOTAL:
Code,you must forthwith comply with such provisions orthla permit shall be
LU j deemed revoked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
M Z Iherebyaffr thatthereb a construction lending agency for the perform TOP �� ELECTRICFEE
ance of the work for which this permit Is Issued(See.3097,Civ.CJ
() O Lenders Name - PLUMBING FEE
LLE- Lender.Addmx QTY: "f " MECHANICAL PERMIT FEE" MECHANICAL FEE
OW ludifythatlhavereadthbappUmlionandstatethattheaboveinfornution
1 iscormR.I agreeto comply with all etyand county ordinances and nate laws PERMIT ISSUANCE FEES PAID:
} N relating to building construction,and hereby authorlse representatives of this - -
Z city to enter upon the abovo-mentloned property for inspection purposes. ALTER ORADDTOMECH. Date Recei ted
(We)agree to save,Indemnify and keep harmless the C,ty of Cupertino - -
V against liabilities,judgments,cateand expenasp which may In anywayaaxue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against yyd C' n coneeAA qu ce o t e grants/If/'tea/If this permit �� -
�'` U/� AIRHANDLINc[iNrr(oven[0,990 CFM) CONSTRUCTION TAX
Signatu Applicant/ .enact r O P Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theappllcant or luturebulldingoccupant store orhandle hazardous HEATING UNIT(TO 100,000 BTU) Date Reeei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Healthand Safety Code Se �n2S532(a)2 HEATING UNIT(OVER 100,000 BTU) TOTA r_
❑Yes L_I"'a
'- Will the applicant or future building occupant use equipment or devices• VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contarid ants as defined by the Bay Area Air
ahty Mawgement District2 BOILER-COMP OHP OR 100,000 BTU)
�J yes
Iha Bread the hazes ou dials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 B7V) pa
the California Health gn Safety Code,Sections 25505.25533 and 25534.1 1,� p tl paw
urdersts rid that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT - n a'7 / yr•�•
- rceponsibiJlliitay/(o to nestIfy the occccuupp�ant oft requirements which=at bt be mot 1 APe
priorJKf�• //Lf Ce IEi�4Kf0 �}� / n'� / .• �a I� a5V/�
GG /E// 4 a
Owner or authorized agent Date ISSUED DY: <�
TOTAL:
OFFICE COPY