23667 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE SALL POINT PEN ONLY
Building Project identification PERMIT NO.
Budding Address: 2 3 6 6 IT7
-S can r -
wners ante: , -f \one: ,
p N-' 8nt�la,CO� 8 CITY OF CUPERPINO-BUILDING DIVISION "a
• C no- or'.Name: ''�1II II,,,, qq LIe Ne:/ APPLICATION /PERMIT
- Uhys.}.',I /. BUILDINGELF TRICALPLUMBINGMFGHAMCAL CATEGORY CONTROL#
Architect/ glnrer. Llr.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrm:, PFRMITISSUANCE ❑ ❑
� LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm that l am licensed under provlsidna of Chapter9(commene. APPLIANCES-RESIDENTIAL JOB DFSC ON
Ingwlth Senion7000)of DiWM.o 3oflhe Buainessand PmfeW ..Code,and my ^ ((
license is In I. rce an effect. PANELS l//���'111l n(n1-/`^•%/
Gcen.Cls ( 0- Lima_D 5 — ! 'O
DaleUT
11- Yo ConlraRarr L ln�f�'Jn 111 ..
' ARCHITECTS DECLARATION 201-1000 AMPS
rx Q O I understand my plana shall he used as public records. OVER 1000 AMPS - SQ.Fr.FLOOR AREAL'�`' /gQ,Ff.
�r4) Licensed Pmfewilmul SIGNS ELECTRICAL"'. a-' IIm �- IN
,
6 OWNER-BUILDER DECLARATION
�� SPE IALCIRCU1T/MLSC - 9
Fj owing a ..(Seh11amexem (romthe Contractors License Law for Arydlyrr y/ I'�� g ��
'Z �
following hereby
exempt
and Professions Code:My forthe �1V ° E R
O Z.. TEMP.METER OR IDLE INST. I
rr„ county strunu ,requima peuNttomrotequirestheareprove,limmi for
such,orrepairto z
gyp
y any structure statement
hat he tat also sed pursuant t the forme nal of t e pOOygg DEVICES
f5 oG floe a signed statement that he b licensed pursuant it the Pon 7000) of the T �-
3u,t� Conweir .aIrc.Law(Cha)rter9(rommencing with Sectlen7000)o(Divi- SWIMMING POOL ELECTRIC VALUATION
OJ the basifothealleed exemption.'
Any
lee.m)n therefrom and
the basis for the alleged exeatheap Any violation ofSection 7031.5 by any OUTLE•S-SWI CHES-FIXNRB5
applicant lora permit subjectahe app0canl to a civil pemlty o(not rtnmthan (6
Bve hundred dollars(5500). SQ.FT. STORIES TYPECONS RUCTION
I,as owar of the property,or my employees with wages as their orae NEW RESIDENTIAL ELECTS
7Q compensation,will do the work and the structure is not intended or offered for
O
.is&m.7044,Business and Pefeseloru Code:The Contractors License Law
$$ docs not apply to an owner of property who Wilds or improves t barren,and - OCCCROIII' RFS.UMTS
whodonsuchworkhlov.lforthroughhisownemployees,pmvidedthat.uh .
Improvements are not Intended or offered for sale.If,however,the building or ' 'TOTAL:
Improvement bsold within oneyearofcomplellon,theowner-bullderwill have
tllmtiarden of proving that he did not build or Improve for purpose o(sale.). QTY, 'PLUMBING PERMIT 'FEE FLOOD ZONE APN s
u L as owner of the property,am exclusively contracting with licensed
contractor to construct the project(Sem 7004,Buslnmand I'mfmlmet Code: PERMIT ISSUANCE 0
The Contractors License Law don no apply to an owner of property who ALTER-DRAIN VENT-WATER(EA)
Wilds or Improves thereco
on, and who contacts for such Piokm with a
cgnj(actor(s)licensed pursuant to the Contractors License Law. FEE SUMMARY
LI I am exempt under Sec. B k P C for this reason BACK FLOW PROTECT.DEVICE. OUTSI UP
17
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N � -
• Owner Dene _ r RECEIPT#
WORKMAN COMPENSATIONDECLARATION FIXTURES.PER TAM SCHOOLTAX Y N
hereby affirm that I have a artlBate of consent m self-Inure,or a
artiBote of Workers Compensation Imurance ora certified!copythereof(Sec. RECEIPT M
38M Lab C) GAS EA.SYSTEM-1 INCA OUTLETS PARK FM Y_ N_
Policy# la99:2- RECEIPT
Comany T?c _._ _ GAS'EA.SYSTEM-OVER4(EA) B LIMITING D I VIS ION FE IS
[P ed copy is hereby te
enified copy b flied withh the city
Inspection dfvlalon. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
ely
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWFJ.SANTTARY-STORM PA 200FT Date Retmi t#
(Ieian need rat tr completed if the pemdt bfaroa hundred doilan
(a100)orm3 a 5
lartiifythal In the per(ormanceof the wak(orwhlrh this permit le blued, WATER HFATFRW/VENT/ELECTR ENERGY FEE Y N
I shall not employ any person In any manner so as to become subject to theWATEt SYSTEM/•fRpA.ITNG '
Workers'Compensation laws of California. Date - PAID
,Q Z ApplicaNOTICE
NEW RESIDENTIAL PLMB. SO,ET. Date Recei t#
.ZO NOTICEco APPLICANT:totheagerces'Co prestionhis Certificate of Exemption,you
H
should ode,yo becomesubjectforthwith
Work ea'such pr salbnp orthts s of permit
the Labor • TOTAL:
LUN Code,you murtfonhwllh comply with each proWiaru orlhb pemdt shall be
> dressed revoked. BUILDINGFEE
aG . CONSTRUCTION LENDINGAGENCY SEISMIC FEE
I herebleaffirm that there b a construction lending agency for the perform TOTAL: �,�] ELECTRIC FEE
Z an.of the work for which this permit b issued(Sec.3097,Civ.C.) ,-e
L) O Lenders Name PLUMBING FEE
LL.I- Lender's Address - Q7Y. ' MECHANICAL PER IT FEE MECHANICAL FEE
O Ili
IootS,"hatl have read this appliatlonand natethattheaboveinformxtim -
ecoreact.I agree to complywith all city and county ordinances and pale laws PERMIT ISSUANCE FEES PAID:
(li
}' relating to building construction,and hereby authomm representatives ofthb
(— U) city to enterupon the above-mentioned property for impaction purposes. ALTER OR ADD TO MECH, Date Recef t#
— (We)agree to save,Indemnity an d kap harmless the City of Cupertino P
agalrat lodes,ydgmenls,cona en expert..which may m.r aye AIR ILANDLING UNIT Q010,ODO CFM) SUBTOTAL, Sy
agai s n .rya of gr 1 of til.permll. ` AIR HANDLING IATT(OVER 10,000CFM) CONSTRUCTION TAX r
oAppllm / t or Dae EXHAUSTHOOD(W/DUC) CONSTRUCTION TAX PAID:.
H ZARDOUS MATERIALS DISCLOSURE
Willlheapph ntorfummbu0dingompantslomorMndlehazardoua HFATINGUMT(T0100,000BT(n
material ai deli by the Cupertino Municipal Code,Chapter 9.12,and the Date Recei tit
I halite and Safety Cade Section 25532W? HEATING UNIT(OVER 100,D00 BTU) TOTAL: i
0 Yes No _
Will the applicant or w m building occupant meequipment ordevices VENTILATION FAN(SINGLERESID) - ISSUANCEnDATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP CIT OR 100,000 BTU) DEC ����
4hYca No
. averead the hexa esus material,requirements under Chapter 6.95 of BOILER-COMP(OVEH00,OOD BTU)
the Califomb Health k Safety Code,Sect Ions 25505,25533 and 25530.I x. x!
undemta ed that if the building does not comely have a tens nq that it b my NEW RESIDENTIAL MECfL SQ.FT CIIY vri;U1 Chiu''
responsibility to not By the occupant of the requirements which moat W met
prior to Issuance of a Cecil Scale of Occupancy.
O.vncrorauthoriud a gent Data ISSUED BY: ,
TOTAL:
OFFICE COPY