23684 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PEILWT NO.
Building Addmae` 23684
1 �¢.�rloSR
wnere aces. one: A
a q, CITY OF CUPERTIN¢B ILDINC DIVISION
ma a..a^.: > s Lk.Na APPLIC TION I P MIT r�l
BOLDINGELCA1,PLUMBING HAMCAL CATEGORY
schuss/Enginser. Lk.No: 1�
': ...c-,-7BU1LDINC PERMIT-INFO�_by^
Address: ISSUANE w I� (01a �j{` –
LICENSED CONTRACTOWSDECLARATION
Iharebyaffbmthatlam lkmaaluaderprovWaneof Chapter9( ANCES L JOB D75CRIIrpION
ingwlth5ect1on7000)o(Dlvlalon3a(the BudnmmdProfmlmuCade d
Ii...is in full(oil and effect. ANES
License Clean Lief • eOD/
Date Contra Cor a ISM
ARCHITECTS DECLARATION '1 M
ceO Zp I understand my ptrns ahaBbe used espublic remrda. O ER AMPS SO.FT.FLOOR AREA f/SQ.Fie
d E Licensed 9 Professional ELECIIDGL (�Qts Sl�V
Z LG OWNER-BOLDER DECLARATION SPECIALCIRCNT/MISC rte"
Iherebyafl.thatlamexemptfromtheCentractoraLlcenselawforthe
QQ fallowing reason.SeNon 70315,Buslnm and P.I.W.Code.Ary city or f4�
t'ty muntywhichrequirnapert tWwmtmL%alter,impmv demolbh,ormpalr � K��ORI'OLE MSI.
W"
E a anyamu mpr rtoid Wuamc alaorequirntheappBmntfmmchpar W POWER DEVICES
y'a RIC•signed statement that he is licensed pursuant to the proWimu of the
30� Contnctore License Law(Chapter 9(mmn.nMg with Section 7000).f DIW- SWIM,MBNGPOOLELECTRIC
don 3 ofthe Business and Profmwu Code)orthu he b exempt theretroneaad VALUATION
S^S the basis far the alleged exemption. Any vlolatlm of Section 70315 by sen a0
0 applicant fare permit rob*uitheapplicaotto a cfWl penalty ofnC tha
mon n UTLETSSWITCH6SFDiTURFS r►� 8 (0
0
GG17� fiv dyed dollan(f500). NEW RESIDENTIAL ELEM_SQFI. STORIES V TYPECONSIRUC170N
�n I, owner of the property,or my employees with wages as their sole
c Hon,will do the work,and the structure is mtbdended or offered for
q Is6ec.7061,Busb¢aa and Profminra Code The Contractors License Law
^ala notappl)ta m owner of property who builds or improv,therms,and I �^ EUNrISwhodonsua 'kh[m lfwthroughh" wnemplayees,pnvldedthatwch We IImprovements areImprovernme Id within oneyearo(complerbrytheownerbuilderwW have .. _ _ _t"rdenof pmWngthat he dM notbuud crimprew forpurpomofsale.k QTY:�;a�i`FLUMBt1VG�PElR1YlIT'-"i'4}� ir_...LJLn owner of the property,am exchWvely contracting with IlcenaM PERMIT ISSUANCESea 701 Bush®aha Pmfmlons Cde:The Contramar',License law does nC apply to an owner of property who
builds or Improves thereoM1 and who contram for such plo)em with s ALTER•DRAIN&VENT•WATER ary¢+Cvr(s)Ilcenad pursuant to the Contractors Lire.Law. .•u�t.�iv,,,,'�'YFEEIS
LJ I am exempt under See B&P C Ian this rerun RACK FLOW PROTECT'.DEVICE
DRAINS FLOOR ROOF,AREA,ODND. SANITARY Y N
er Due _ RECEFr It -
,_ WORKMAN COMPENSATLON OECIARATION FO(71IRES PER TRAPSCHOOLTAK Y_ N
❑I hereby affirm rAu I luso a mrtlflcatr M censers(to.H•bmtre,m a —_ RSCE r I
4�•" mrtHlcateofWorkm'CmnpensaHanlnsuranmwattrtlfled ropy NemfSee •_
Polis Li•b CJ GAS EA.SYSIFM•1NG
Polity OIfiI.LRS PARKFEE , Y_'N_
. : RECEPI a
Com - GAS- A.SYS(EMOVERI(EA) .-BUILDNGDIVI ONFE
Cra2yd copy is furnished.hereby
GREASE/WDUSIRL WASTE INIUCEPTOR PLANCH E
CartBTedM-d ropy is Ned with the city Inspection division.
GREASETRAP PAI
CERTIFlG MPE SATIONON MOM WORKERS
CONSAT10NNSURANCa SyyEFSADHTARY.SIORMEA 2WFT. Date Reeel 10
(Ddsaectlon need no ba complued tithe permit is(monshundred dollars -
mm)orlmJ t WATER HEATER W/VENT/EFCT'R CY FEE N
I ttrtUythu lothe per(ounsnm o(thework ferwMch this permit b blued, � .
I shall not employ any Person e In my manner so as to becomsubject to the WATER SYSTEM/IRPAID
EATTNC
Workem'Compensation LAws of California.Date
Z NEW RESIDENTIAL PLMB._SQFT.
0 PP NOTI ETO APPLICANT: rnsking thisCertHlateaf Exemp[loM1 you licant Date Retxf t#
should become subject to the Worken'Compenation provisions of the Labor TOTAL:
~ N Code,you rnuat fotthwlth comply-withsuchprovisions or this permit shall be
LU > descried nemked. BUII DING FEE
Q. CONSTRUCTION'LENDINGAGENCY SEISMIC FEE
I hereby aNrm that them lea construction lending agency for the perfamt ELECTRIC FEE
:DZ mm oftheworkforwhichtwpermltbbwed&e 309/,Clv.CJ _
00 Iaadera Name . ,. '
LL h Leaders Add. (Try. CHANICAMPERMIT, A FEE'4 MECHANICAL FEE • ' re
O W I mnifythatl have readtwappllmtbnard statethuth.above lnfomutim
ismr .lagrmrocorpiywithaudtyandcountyoNWummdsta .nor PFRMITISSIIANCE F'EF_SPAID:
} N relating tobullding constmaino,and hereby authmim representative oftw
W city to enterupon the abovermentload proptiryforimpectimpurpoem. ALTERORADDTOMECH.
(We)spm to as",indemnify an d keep hamdm the City of Cupertino Date Recei t#
V agaWtllabWtire,Ind expensesall
whlth y In m 10,000 CFM)AIR HANDLING UNIT LTO 10, CFM)
age �iaque o sting dtw pe SUBTOTAL•
r, ,� /&� 'Z AIR HANDLING UNIT(OVER 101000CFT, CONSTRUCTION TAX
read Applicant/Contnctm Date D(HAUST HOOD(W/DUCT, CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
ft:21..
the applicant or future bullding omapantrtme.,handle harandoua HEATING 100,000 am Date R ei
defined by the Cupertino Municipal Cade,Chapter 9.12,and the
Health and Safety Codei�SMion 25532(a)? HEATING UNIT(OVER 100,000 BTL,
n❑Yn L�Ne
Wllthe ipPlkant orfumre building can pant use equipment or devices VENTILATION FAN DINGLE RFSTD) Cf ISSUANCE DATE '
which emit harardous ab contaminants as defined by the Bay Area Ab ,
Quality Mmagement Dbtrtct2 BOdER-COMP DHP OR 100,OM BTU)
( I�I Y:l Q No
J Eeve read the baraaue materfala requirements under Chapter&95 of BOILER-COMP(OVER 100, BM
the California Health&Safety Code,Sections 25505,25533 and 25531.I
understand that ifYton notihe fy
uilding the—part nm mrrentiremem.which=at
mat NEW RESIDENTIAL MECH. SQ.F7.
responsibs ltyce nm aytheiate of ofthe rtqubemenb which mual be met ^
prior to issuance d a Certificate of Occupancy. \rJ
Owneroraurhodred.Smt Date L =\ a�ISSUED BY \ z
M Y �
OFFICE COPY