23063 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PFRMITNO.
BuIlding Address: . 23063
If ors N. D�wZA &VA
roe• one:
CITY OF CUPERTINO-BUILDING DIVISION 1 n f >p _ {� '
c°nmM .Nam: 3Lie.N. APPLICATION /PERMIT l arW— �
BUILDINGELMMCA4PLUMBING-MECMNICAL CATEGORY CONTROL#
Arch lte /Engineer. Lk.No:
/s/sr� QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:/WJJ
PFRMITISSUONCE Tsa ❑ ❑ ❑
LICENSED CONTRACTOR'S E LARATI1 �J
I hereby affirm that l am licensed under provisions o(Chapter9(commm APPLIANCES ENfIAL JOB DESCRB'DON
Ing with Sesticn700mof DIvW on3o(the Buatrs,ssand Pro&satonsCede,and my �
Income Is In fuR fors and dfcH. P
LlcenseC6ss LILY
Date Contractor
ARCHITECT'S DECLARATION 1-1000 AMIS
09Z nderstand my plans s1u11 be used as public records OVER 1D00 AM SQ.FT.ILOOR AREA f/SQ.FT.
Oats
Licensed Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SI`DCIALCBCUIT/M1SC
Z� I herebyaffirm that l am exempt fromthe Contractor's License law for the
pp following reams.(Section 70315,Business and Professions Code:Any city or
2 i. 7FA1I'.METIR ORIOLE INST.
� eountywhlN ecPrlmapermittomretrue;alter,4npmve,demollsh,or repair
t < anystructure priorto Rs Issuance,also requiresiheapplicant forsuch permit to POWER DEVICES
S V ale a signed statement that he 6 licensed pursuant to the provisions of the
3w� Contractors License I..(Chapter 9(commencing with Stolon 7000)of Diel-SOS Mon 3 ofthe Business and Prom SWIMMING TOOL ELECTRIC VALUATIf I�I('�feeloCode)mthat he 6 exempt therefrom and C ,asr�Yss��9 the Mae for the alleged exemption. Any violation of Section 70315 by any OUTLETS-SWITCHES-FIXTURES L/1'000 �-
appllant fora permit wbjects theapplicani to a ciW I pemhy of not mmthan
$ five hundred dollars($.5+0).
7 ❑I,as owner of the property, NEW RESIDENTIAL ELECTR SQFF. STO1BES TYPE CONSTRUCTION
p perry,or my employees with wages r thele dole
C c mpensetion,wlsinessdo work,Prods toes roccum Code:
Contractorot Intended oroffered
'$ O sale(Sec 7636,Business and Professions Code:The or improves
Llama Taw
whoducdoes net epplytornownelofproperty ughhisoWilds nempoyees,povidedron,and OCC.GROUP RES.UNITS
CC whodoesrtmhnts amwork hlmaededorofferedowne.If,hoes,pethe bildingthat h
Improvements are not Intended proffered for sale.th howe r-rude buildingve TOTAL:
Improvement6w7dwlthlnomyearofcomplMlon,theowner-W llderwlllhave
thLIpMenofproving that he did not build or Improve for purpose cf..10. QTY, PLUMBING PERMIT FEE FLOODTDNE APN
Lj L as owner of the property,am exclusively contracting with licensed pggMyp ISSUANCE
contractors m construct the project(Sen 7094,Businessand ProfessionsCode:
The Cantnctor's License Law does net apply to an owner of property who ALTFA-DRAIN lc VENT-WATER(EA)
Wad.or improves thereon,and who contracts for such p(ujem with a FEE SUMMARY
contracor(U Hemsed pursuant to the Contractor's License Law. BAIX FLOW I'ROT[C7.DEVICE
LJ I am exempt under See. B k P C for this reason
OUTq[DF FEES
DRAINS FLOOR RODE,ARE A,COND. SANITARY Y N
Owner Date RECET T p
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certNnte of consent to self-mare,or FIXTURE%PFR TRAP SCHOOL TAX Y N
certificate of Workers'Comperuatloelesurance ora cer11f6d ec
copy thereof(S . RECEB'f Y
3900,Iab C.) GAS EA.SYSTEA3-11NG60I1TLET5 PARK FEE Y_ N
RECEIPT Y
Polity Y OAS EA.SYSTEM-OVER 6(EA)
Com any BUILDING DIVISION FEES
a Certified copy 6 heed with the
city CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE 11 ',gig
Certified copy is Ned with the city Inspection division' —1 D
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 2(IOh1' Date Rett'1 t#
(Thlssectloo need net be completed if the permit 6 forces,hundred dollars
(f10emican.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
l eertifythat In the performance of the work forwhich this permit[seemed,
I shall not employ any person In any manner w as to became subject to theWA77Bi SYS[77d/TREATING
Worker'Compensation laws of California. Date PAID
O Z Applicant - NIEW RESIDENTIAL PLMB. SQFT. Date Recel t#
Z O NOTICE TO APPLICANT.11,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
CC N Cade,you must forthwith comply with such provisions orth6 permit shall be r-+
W > dremed revoked. BUILDING '
EE
CONSTRUCTION LENDING AGENCY SEISMIC FEE 1
t1 I hereby aBir h that there 6 a construction lending agency forthe perform- ELECTRIC FEB
M Z an oftheworkforwhlchth6permit66wed(Sen30B7,CIv.C.) TOTAL:
U O Iender'eName PLUMBING FEE
1— ]endee.Addresn QTY.I MECHANICAL PERMIT FEE
O W Icorti(ythat I haveread thIsappliation and statethattheabove Information MECHANICAL FEE
S is correct,Iagree to comply with all city and county ordinances and pate laws PERMIT ISSUANCE FEES PAID:
>. ILL tobullding construction,and hereby authorise representatives ofth6
H N city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
? (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Recel t#
V agalhat fish s,jud ncnb,coatsand expenses which mayln anywayacwe AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL:
agalmt sal tyb ne�uence o(the granting o(thls rtnis
Z� AIR HANDLING UNIT(OVER IQ0DLCrM) CONSTRUCTION TAX
° CONSTRUCTION TAX PAID:
Sigmm o(Appllant/Ce3traM Date EXHAUST HOOD XAZA OU IATERIALS DISCI.OSU0.E ,
Will the applicant or future Ilding occupant store orhandle hazardous HEATING UNIT(TO 100,000 BTS!) Date Recei t#
material as defined by the Cupertino Municipal Code Chapter 9.12,and the t 96Z
Health and SafMy Code Section 25532(.)1 HEATING UNIT(OVER 100,000 BTU) TOTAL:
RYes No
ill the applicant or tura building occupant use equipment or devices VENTILATION FAN(SINGLE MID) ISSUANCE DATE
which emit hazardous air comaMm nts as dell ned by the Bay Area Air
�J Ilty Management District? BOILER-COMP OHI'OR 100,IXD BTU) PAID
1 p B D
�Yes he ❑N° B' Pl V
INferead ealth&Safet materialsodeSe reonsfirchnents 5,2553 and 25534.
6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health dCode,Sections25505,25533have
a tenant,andthat ] ' ,r
understand that nthebuildingtheocdpes oft erequire encs whichthat It met NEW RESIDENTIAL MECH. SQ.FT DECIG (} 1999
responsibility to notify the occupantdlhe requirements which=at be mM q Y
priorto Issuance of a Certificate of Occupancy. CI1 r Vr
_ curtn �
Owner or authoriard agent Date ISSUED BY:
TOTAL:
OFFICE COPY