23476 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification P' TNO.
Building Address:
/0�4� Fasf ZSrhv�es !�i/ ✓vZ
3476
wnero a one: A A A
32' 8 CITY OF CUPERTINO-BUILDING DIVISION
ddh G°^tr or'#Name? '3 � CATEGORY CONTROL
c.Nor APPLICATION I PERMIT
ArrMtect/ BUILDING-ELECTRICALPLUMBING-MECHANICAL #
ghee Lie No:
/ QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add Of J./ z pERMITI55UANCE ❑ El 1:1LI F.NSED CONTRACTOR'S DECLARATION
I hereby affirmthat l am licensed under provWonsof Chapter9(monotone APPLIANCESRESIDENUAL JOB DFSC
Ingwith Section 7000)of DiWsion3ofthe Businessand Profes moCode,and my yy �#
Ilccnselsinful anddrect. ��d31•Gr PANELS
LlcenseC ss Lle#
Dale Contractor
ARCHITECTS DECLARATION 201-1000 AMPS
C7C7 I understand my plans shall be used as public mcnNs. OVER 1000 AMPS NIFT.FLOOR AREA S/SQ.FT.
ZU Licensed Professional S[GNS ELECTRICAL \tl1
<Xw OWNER-BUILDER DECLARATION GON&i
Iherebyalflmn But lam exemptfromthe Contractorb Llrense Law fa the SPECLIL CIRCUIT/
UA[n
pp '� following reason 6actlon 70315,Business and Pm(essions Code:Any city or
TEMP.METER ORl'OLE INST.
county whlch requlresa#entero.constmuirintheaprov,demofish,ormitto
anyrtructure prior to its tssuame,also requlrestheappBant for such permit to POWER DEVICES
file a signed statement that he Is licensed pursuant to the provisions of the J
Contractor's LkertnLaw(Chaptar9(mmmencingwithSection 7000)ofDivi. SWIMMING POOL ELECTRIC
I„pj03 elon3ofthe Businessand Pror mCode)orthatheisesempttherefromand VALUATION
Y-' the basis for the alleged exemption. Any violation of Section 7MLS by any /� a
<5.
applicant for permit sub' OUTLETSSW[TCHESHXTURFS
pp pe lees the applicant to #entity of more than
A. nC~u live hundred dollars,($500).
7 ❑I as owner of the NEW RLSIDENTIAL ELECTR SQ.FT. STORIES YPECONSTRUCTION
, property,or my employees with wages as thele sole
< cam(Sec.7Kwill do the ess and Promathe,structure h ren intended
ot'o?cense offered Law
❑ sale(Sec.7614,Business and PMesslom Code:The Contractor's License law
�$$ does not apply to an owner of property who builds or improves thereon.and OCC.GROUPRES.UNRS
who d.essuch work himselorthr°ugh his own employees,provided that such
improvements arc not Intended or offered for sale.Il,however,the build ing or TOTAL:
improvement issoldwithln°neyearolcompietlon,the owner-builderwlll have
th Nen of proving that he did not build or Improve for purpose ofsale.). QTY. PLUMBING PERMITFEE FLOOD7DNE APN
1,as owner of the property,am exclusively contracting with licensed pFRMTI'ISSUANCE
contractor to consec construct the project(S 7044,Business and Proassbm Code:
The Contractor's License law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER ffN
builds or improves thereon,and who contracts for such projech,with a
co actor(,Boomed pursuant t.the Contractor's License Law. gA�plpWpgOTECT.DEVICE FEE SUMMARY
I am exempt under See B k P C for this reason
Owner Date DRAINS FLOOR ROOF,AREA,COND, SANITARY Y_ N_
. WORKMAN COMPENSATION DECLA
Of
heRATION RECEIPT'#
reby affirm that I have a artlficate of consent to self-Insure,or FIXTURES'PER TRAP SCIdtTOL TAX Y N
certillate ofWorkeri Compensation Wurance ora arti(led copy thereof 6ec. - RECEPrIs
38W YbQ n ^� GAS F.A.SYSTEM-1 INCAOUTLETS PARK FEE Y_ N_
Com any �/ O� _ CAPA. RECEIPT#
�Cemi(led copy is hereby furnished. eY 6 S BUILDING Div]SION FEES
i�C:ectifred copy le filed with the city inspection it lvision. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF O(EMPTIO.N FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWERSANITARYSTORM EA X F7' Date Reeei t#
Qhtssectlon need nut Le completed tithe permit is(or ane re
hundd dollar
($1 fytWATER HEATER W/VENTMENERGYFEE Y N
Iunify that in the Performance of the work for which / ECTR
hehla permit leissued, —
I shall not employ any person In any manner an as to become subject to the WATER SYS77]N/IRE UI
Worken'Compenvtkm awsof Callfomla.Date PAID
O Z Appllcim
Z 2 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMR SQIF7. Date Recei t#
FshouldbecomesubFd tothe Workeis'Compematlon provlslonsofthe Labor TOTAL:
N Code,you most forthwith comply with such provisions.,this permit shall be �a
LU > deemed revoked. BUILDING FEE
d G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that them Is a contraction lending agency for the perform Tornl: ;BIN
FEE
O once o(the work for which this permit blswed 6ec.3097,Civ.C.)
u2 Lender's Name FEE
LL H Lenders Address QTY. MECHANICAL PERMIT FEE AL FEEOW IartBythatlhavercadthisappliatlonand atatethattheabove ln(ormatlon1 lacorrect.l agree to comply with all city and countyordinances and nate laws PERMIT ISSUANCE} relating to building construction,and hereby authomm representatives of thisF Z city to enter upon the above-mentioned property for lmpection purposes. ALTER OR ADD TO MF-CH.
(We)agree to save,indemnify an d kap harmless the City of Cupertino - Receipt#
agaWt hitInities,judgment,costs and expensm which may lnanywayacaue AIR HANDLING UNIT(r010,000 CFM) SUBTOTAL•agasaid Gtyi onse en (the rung of this permit. /� � � ,���s/ _ AIR HANDLINGUNIT(OVER10.000CR) ION TAXb amre of Appllc t/Contractor 7 Dha ^� FFxHAUSTHOOD(W/DUCT) TION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building—Not store or handle hazardous HEATING UNIT(TO 100,000 BTU)
material as defined by the Copan].Municipal Code,Chapter 9.12,and the RL'Cel t#
I lealth and Safety Code Section 25532(A)? HEATING UNIT(OVER 100,000 BTU) TOT
❑ Yes �]No
Will the applicant orfutum building occupant use equipment ordevices VENIILATIONFAN(S1NGLERESID) ISSUANCE DATE
which em
it hazardous air cooUrcho nts as defined by the Bay Area Air /
Qu lfty Mawgerrcnt District? BOILER-COMP QHP OR 100,0(10 BTU
4Ys No ry
havercadtheh Safety
Code,Sontoniremenbundeand2553r6.95°! BO LER-COMP(OVER1%,000 BTU)
the California lieallh k Safety Code,Son tons 25505,25533 and 75534.I
u ndenta nd that it the build big dont not cogently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FF. ���
r
prior
to issuancty toe
of a Cthecate of tofthe
ity. sntswhich must bemet,
prior to Issmnce of a Certlfkate of Occupanry.
(I
Owneru,authonzedagent Data
s7
IOTA L:
ISSUED BY: L•slh.ke
OFFICE COPY