23836 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Hu-11ding Prate t Identification Pk7tMITNO.
Building Address:
s N,so Ave- 23836
,vner,Nares- Phone:CTQp g` P_ I�.irL�Av/ a5-14 -2 CITY OF CUPERTINQBUILDING DIVISION Ar_ J��i -
c°"'1r}'s�/°°re
NO
: II Lie.No: APPLICATION I PERMIT V" L II
�• -f'] � ���r�C- �� 6"kip7� BUILDINGELECTRICALPLUMBINGMECHAMCAL CATEGORY CO O
ArehlteR/F�g�rer. Lt.No:
BUILDING QTY ELECTRIC PERMIT FEE PERMIT INFO
Address, l: �� f4— PERMITISSUANCE �� ❑
LICENSED CONTRACTOR'S DECLARATION El
Humbyaffirm that l and licensed under pm,bdomof Chapter9(mmmenc APPIJANCESRESIDENIIAL V21OH DESCRIPTION
'ngwith Sectfon7000)of Dvhdon3 ofthe Bustnnsand ProfesslonsCode,and my
license is In full rce and effect. PANELS
Limns.Class_ a_Lk.p 6y no 9'K I�QpI
Date Contractor
ARCHI=S DECLARATION 701-1000 AMPS
het I understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/S .
❑O
(/ Licensed Professional SIGNS ELECTRICAL 2
Sp OWNER-BUILDER DECLARATION SP[CIALCItCU1T/M75C
Iherebyaffirenthatlamexempt fromthe Ccerachor's License law for the
0 9 following reason.(Semon 70LLS,Business and Professions Code:Any city or
O L 1-. TEMP.METER OR POLE INST.
ps�m county which requires a perm¢to construct,alter,Improve,demollsh,or repair
aCE'< anystructure prior to Its issuance,abo requlresthe apphmnt for such permk to POWER DEVICFS
r�C G D file a signed statement that he is Ikenseci pursuant to the provisions of the
Codurind.esL
rense
030 sion3oftheButsmesslnd(Prof iom Coeorhatthelsemmht�fmmand SWIMMING POOL ELECTRIC V�ALL Tit]'!1/.�
a g he basis for the alleged exemption. Any violation of Section 7031.5 by any OUTI.EISSW1MHESFIXTURES' V�`r
llmntfora Mt sub els the applicant penalty fent nnmthan V YV
'aPP Per le PP Pc Y°
five hundred dollars(SM. NEW RESIDENTIAL ELECT¢
SQ.FT. SfOI41 ES TYPECONSTRUCTION
Ej I,as owner of the property,or my employer with wage as thele rule
C 7.a .1.elecamponsa0°gwWEothework,andthestode:Th red Intended orofferedfor
�p sole not apply.700A to alnowner of propeProfessionrty
Code:The or imrovesthemeoLaw
aW $
does netapply to ownerofpropertywho WIenporImprovesthereon,and
G 5'-
who dcessuchwork hlmseBorthrough hisownemployees,provided that suchOCC.GROUT' RES.UNITS
m
improveents are not Intended°roffered for sale.Ifhowevegtheinildingor TO L
improvement bsold within oneyearofcomplolon,the owner-buklerwlll have
th rdenofpmving that he did not build or improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE
Fl000zoNE nPN
1,as owner of tdthe propend, Se exclusively Business
contracting with licensed PERMIT ISSUANCE
contractorto comtmct the project(Sec.apply
Business and Iof property
Code:
The Contractor's es the Law don ort apply tct an fee
of property who AL. III-xx Is as
� I
builds he Improve thmon, and who matrons foe such p ojetts with a
m,ttLLt,ractor(s)Rmnaed pursuant to the Contractor's License Law. BACK T FEE SUMMARY
LJ 1 am exempt under Sec. e A P C for this masontxxx,a
DRAINS 1T.0OUTSIDE FEES
0 R SANITARY Y_ N
Owner Date '���T�.�--cccc..,, RECFL'C R
WORKMAN COMPENSATION DECLARATION MTURESWATE%- ?, iOOL TAX Y_ N
ercby affirm that I have a mrtiRmte of consent to coif-invrrc,or AFLFTPT M
jr ilicid cd Workers'Compensation lmuranm ora cenBied mpythereof(Sec. GAS FA.SYSTF.M-]INC.40UILEIS AAK PEE Y N
38 ,lab C.
Policy M RECEII'f p
GGAS FTI-0
EA.BYSTVER 4(EA) BUILDING DIVISION FE ES
rFCa"y ertlfied copy Is herebytumcity GREASEANDUSIRL WASTE INTERCEPTOR PLANCHECK FEE a� It Certified copy V filed with thecity inspection division. 6
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 2(3017 Date Reeel t#
(This section need not complctM tithe permit 6 for one hundred dollars
CSf I cedifess.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Imm(y had ropl.the pension 1.an thewoek ferwhkh conn.,his rmRts tamed, —
I shall not employ any penton In any manner m az to become subject to the WATER SYSTFM/TREATING
WorlicCompematlon laws of Gllfomla. Date pAlp
O Z NOApplicant Date Rccei t#
Z O NOTICECE TO APPLICAM:IL after making this Certificate of Exemption,you hIElV RESIDENTIAL PLMB. SQFT.
should become subject to the Worker'Compematlon provlsiom ofthe Labor TOTAL:
fA Code,you must forthwith comply with such provisions;orthis permit shall be y
> deemed revoked. BUILDING FE
a.W p CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that them Is a mmtruR(on keding agency for the Fettered-
Z anm of the work for which this pormlt is LsnedTOTAL:(Be,.3097,Civ.C.) ELECTRIC FEE 116aL
V O 1<"does Nitrite PLUMBING FEE
LL f Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
WIced lfy that l have reaad this appllmtlon and state that above toformation
is correct.I agree to comply with a 11 city and county ordinanm and state laws PERMIT MSUANCE FEES PAID
M :
} relating to building construction,and hereby authodue repreentative ofthis
F U) city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
V — (Wo)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
against llabilitie d"ree ,mrtsand expenses which In anywayattme AIR HANDLING UNIT(TO 10,000 CFM)
againstsald onsequence o(th anting of th�ryp�mLL SUBTOTAL:
r I/ 6�S 9 AIR HANDL NC UY (OVp 10,0000 N) CONSTRUCTION TAX
Signature fAppllmnt/Contractor --�X Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wllltheapph Iorfutum building occupant store or handle havardous HEATING UMT(TO 100,000 BTU) Dale Recef t#
eraterul as defined by the Cupertino Municipal Code,Chapter 9.8,and the
Heahhand SafetyCode Socion25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTA d
YesN No
- Will the applicant or future building occupant use equipment ordevices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which emit luvardeus air contarNnants as defined by the Bay Area Air
Quality Management District? BUTLER-COMP OFR'OR 100,000 BTU)
Yes[
II��N
have mad the hazy?have requirerrcnts under Chapter 6.95 of BOILER-COMP(OVER100,000 BN) q p+r
the California Health k Satfcty Code,Sections 2.5505,25533 and 25534. I U C/
understand that if the building does not currently have a tenant,that it k my NEW RESIDENTIAL MECH. SQ.Fr.
responsibility to IssitycenotifyCelli cafe of ccupanof the equlrements which must berM ���
prior to Issuance ofaGrtifkatc of Occupancy. ��p, 1
Owner or authorized agent Date ISSUED BY.1V t
TOTAL: vsls
OFFICE COPY