20289 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY:
Building Project Identification PERMIT NO,
_BuildingAdd
Ov�� CO�C�Tc c� �vsy 20289
n\C\w- �y��jal'do 2.023 1 CITY OFCUPERTINO-BUILDING DIVISION
Contractor'.Nana:: LIc.No: APPLICATION / P_ERMIT C _
UAC- '1114 u,,-) ¢ S r CATEGORY - CONTROL#
'Architaci/Engineer. Lk.No: BUILDING-ELFCTRICAI PLUMBINGMECHANICAL'
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add..
PERMITISSUANCE ❑ ❑ fdl ❑'
LICENSED CONTRACTOR'S DECLARATION J�4
I Mrebyaffirmthatlamlketeedunderprovblonaof Chapter9(rommm APPLIANCESRESIDENITAL P ]OB DESCRIPTION
Ingwith Section 7000)ofDlvimoo3ofthe Bumnessand ProfeaalonsCode,and my !,
iI.e.le In((��0I(o and effect. PANELS -
LlmnacGhasl.t l L(c.N 2o23V •. /1 +.,x, tI�
Date Lft- —Contra o .R. PI V 'sv'L.•V
ARCHITECTS DECLARATION 201-1000AM -
reOplundcmtandmyplamshallbcuwdmpubOcmcmds. OVERI000 FQ.FT.FLOORARFA I S/SQ.FT.
(/ Licensed Professional SIGN EIEC L ZI 4 -
6 OWNER-BUILDER DECLARATION SPEC LC T ^
Zf., a- Ihembyaffimthatlamexemptfromthe Contractors Lldve lswfd the /
O g.. following reason.(Section 70715,Business and Professions Code:Any city or O LENST.
Fcauntywhkhrequimsaper ttommtmct,atter,impmve,de=lbh,orrepair
gny stmature prior to Its Issuance,also requlm the applicant for uch permit to In DEV
C5 file a signed statement that he b licensed pursuant to the provisions of the
3w Contractor'sLkewe Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
OJ sion 3 ofthe Business and Professions Code)orthat he is exempt therefromand
Q'7 Ile basis for the alleged exemption. Any violation of Section 7011.5 by any OUILETSSWITCHESsFln-URES
555 applicant fora permit subjectsthe 6pplicanttoa civil penalty elect narethan
fiv hundreddollers(S500).
.• oil,as owner of the ro NEW R] IDENTIAL ELECTR SQ.Fr. - STORIES TYPE CONSTRUCTION
�n p perry,or my employees with wages r Ther door
C G roe(Sea 0Kion,willdoBuguelheworkandthemmciurebnm intended oroffered
❑ dale bee 7004,to shower Prolwlom who builds
orimprThaCcuitea2ols License Law
$$ does not applysauch work owner of property whonempoyees,povidedowds reoryand • OCC.GROUP RES.UNITS
who dceaeuchwork hlmeeBorthmugh his ownemploym,provided that such
Improvements are not Intended mWered forsale.If,however,thebuilding or TOTAL:
Improvementbsold withinoneyearofcompletion,tine owner•bullderwlll have -
tl�ardea of pmving that he did not build or Improve for put rpoae of mkJ. QTy, PLUMBING PERMIT 'FEE I1.00D'/ONE MIN -•
u L as owner of the property,am exclusively contracting with licensed = PERMIT ISSUANCE'.
contractors to conslmct the project(See 7044.Buglne.and Professions Code: .2—00
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN&VFM-WATER ffA) DD
de or In aagqvveeethereon, end who contracts for such ploJecb with e
'� ,e) Im7ed pureuant to the Contractors License Law. - FEE SUMMARY
a pt unci Sec. B &P C for this reawn BACKFLOW PROTECT.DEVICE
g DRAINS FLOOR ROOF,AREA, SANITARY Y N_
. Ownc Da4�j ON RECEIPT=
WORK MAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAK Y_ N
❑1 hereby affirm that I have o drtaranc of consent to ett-finsure,ora RECEIrT 9
certificate o(Workere'Compenuatlun lruurand ora drcl(led ropythenoof(Sec. GAS FA.SYS!'FM-1 IN AOUTLETS I PARK FIS: Y N
3800,Isis CJ '
Policy p GAS Ii1.SYSTEM-OVER 4(EA) RECENT d
Co. any BUILDING DIVISION FEES
Certified copy is hereby fit with the
CREASE/INDUSTRL WASTE INTERCEPTOR " PLANCHECK FEE '
Certified ropy b filed with the city Inspection division. '
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID
COMPENSATION INSURANCE SEWERSANTfARY-STORM FA.200F7. Date RCCCI tN
TThissection need not be completed lithe permit b for one hundred dollars
(510(fitrilesn) WATER HEATERW/VENT/ELECTR - ENERGY FEE Y N—,
-
Idnotthatinanyprsonin the oflhewnerseIork s tobecmesmjectit is to theed, _
I shall not employ any person In hl manner w.to become subject to the WATERSYSTEM/TREATING
Workcr%Compensationhwsof Gll(ornla. Date .OQ PAID
Z Applicant - NEW RESIDENTIAL PLMB. Date Remi tit
Z O NOTICE TO APPLICANT:If,after ma king this CercRleate of Exemption,you —�'IT''
Hshould be..subject to the Workers'Compensation provisions ofthe all TOTAL:
IY N Code,you most forthwith comply with such provlslmu orlhb permit shall be
LU > deemed revoked. _ BUILDING FEE .
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Ihereby offlrmthat there is a construction lending agency for the perform ELECTRIC FEE
Z and ofthe work for which thin permit bbs3097,
tested TOTAL: Dp
V O Londee.Name - PLUMBING FEE W-001
LL ~ Landers Addreea QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W IcertlfythatIveread thbapplkStbnand mmelhallhc above information
C Iscormct.I agree to comply with all city and muntyordinanms and mate laws PERMIT ISSUANCE.., FEES PAID:
}'N relating rob ding coistmctlon,and herby authadae rcpremnmtivcs of fhb '
F.. citytoente u the abovo-mcntloned property for Lpectlon purposes. ALTEt OR ADD TO MECH. Date .ReCel tp
Ve)a to save,Indemnlly,an d keep formic.the City of Cupertino -- P
a O1 011 ,judgments, sand expenses which may In seymyacaue AIR HANDLING UNIT Q010,000CFM) SUBTOTAL: -0
said sen en the granting of this perm AIR HANDLING UNIT(OVER 10,000CF-M) CONSTRUCTION TAX
y �y�R CONSTRUCTION TAX PAID:
Signature o(AppBcantARDOUS Date IXIIAUS'f HOOD(W/DIKT)HAZARDOUS MATERIALS DISCLOSURE ,
Will the applicant the urc ruin ng Municipan oIle, haptenhandle1Z and
HEATING UMT(TO 100,0000TU) C Date Refill tis
material as Safety by the Cupertino Municipal Code,Chaptcr9.12,and(he - - - 1ry?
Fleall ye, Safety Code Section 25537(x)7 HEATING UNIT(OVER 100,OW 8Tln TOTAL: _ (A.
R❑ ll t Ir�-I,No
ill the apardous rfumm building ocmpandby the Bay Area devices VFNDLATION FAN(SINGLE REBID) ]5 a� I)DA:I'E -
whkheMthagement air mnla Mnants as defined by the Bay Arca Air
Quality Management Disldci7 BOILER-COMP OHPDR I00,000 BTU)
4 Yea F-I Na
have read the bazar�ous matimah requirements under Chapter 6.95 of BOTLER-COMP(OVER 100,000 BTU) F 7
the California health&Safety Code,Sections 25505,25513 and 25534.I _
understand that lithe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.Pf.
responsibility Qr CBBBftIBO
ponsibility to notify the occupant of the nequlrcmo
ments which at be met Y Il
prior to issuance ora Certitkate ofOmpanry. - '
Owncr or aulhorlmd agent - Data J. Y� 1/
TOTAL: ISSIRiD BY:
OFFICE,COPY