23842 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE,BALL POINT PEN ONLY
Building Proen Identification 7 PERMIT NO.
Building Address: - L•-
238 A 2
'7 OG�3S i el►t X0,1 1.�r G VS o 4
r� ame: n o �r fPhone:
/! 9A/C�N F Gdck 4,4 �y69 CITY OF CUPERTINO-BUILDINCD VISIyPN
Contr rto<aNa/1 LIc.No: APPLICATION / P R F'1✓ ^ Z-
[/
Al C�la+C �✓�• YQry y� .f�P BLnDINCELFCTRICAL.PLUM N HAMCAL CATEGORY CO �/�
Archlte Englrteer. - Lie.No: a/�+
QTY ELECTRIC P R T FqE BUILDIN9 PERMIT INFO
Address:
PERNUAISSUANCE -
LICENSEDCONTRACEOR'SDECLARATION t
I hereby affirm that l am licensed under provisions of Cha pier 9(rommen A L JOB DESCRIPTION
ingwith Section 7000)ot Dlvlslon3 ofthe Businfe�mandlrrofesslonsCede,and my 1
Brener lsliag (o .ns,effeR.
LicenseIhm .
Contractor Oats Contractor
ARCHITECTS DECLARATION 2014000AMPSA
q�+9z I understand my plamelsll be used as publicrcmrds. O 1000 SQ.FT.FLOOR AREA _ S/SQ.Fssl'.
'n,•'d I Licensed Professional - 9CNS ELEC Lel 3,X
OWNER-BUILDER DECLARATION / •W l GJ
IherebyafOrmthat7am exemptfromthe Cmdractorb License Lawlor the 9'ECIALC T M
followingreas quimctlon703L5,Bm"d and Pimp e,* Cmle h,ytltyor mpair TEMp.MEFFftO LE INST. b
P countyctom require se peuNtta arson uireatheaprovgdemoWh,armitto
any assigned pnorra Its Issuance,he
also rersuant to the provisk permit t e 'I
O��` file a signed statement fedi M is licensed pursuant to the prov0lov of the POWER D� ES
3u' Contractor.License Law(CMpter9(rommendng wllh Section 7"111 of Dlvl- VALUATION
SOS stan3olthe Business and Profembm Codelonhatheisexemptlhercfromand Gi00L ELECTRIC -� �o
the basis for the alleged exemption. Any violation of Section 70315 by any O ETSSWITCHFSFIXTi/RES Cl os,
papplicant fees permlbubjects the applicant to a civil penalty of not room than_ a
{Q� flue hundreddolisnhepr. SQ.FT. - STORIES - TYPECONSTRUCTION
❑I,as owner of led property,or my employees with wages as their sole NEW RFSIDEN77AL F.LECTR I � � � � i
$X7� compensation,will do the worktand thertrocture is not Intended or offered for IN
O sale(Hoc 7&4 Busloces and professions Code:The Contractors License Law 'V
$� docs not apply to an owner of property who build,or improves thereon,and
who doca suchwork himself or through his own employees,provided that such
Improvements,are not intended or offered for sale.If,however,the building or TOTAL:
Improvement issold withlooneyeamfcompletlon,tha owner-bullderwill have
the burden of proving that M didrun Wild or Improve for purpose of asks.). QTY, PLUMBING PERMIT FEE
L as owner of the property, D P
p perry,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to constmct the project(Sec.7044,Business and Professors Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WAIIIt ff-NN
halide or Improves thereon, and who contracts for such ptn)ena with a Q
y,➢11(T++Osiris)Brensed pursuant to the contractors Llmbse Law. FEE SUMMARY
c fJl am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE
OUTSIDE FEES
Owner Dale DRAINS FLOOR ROOF,AREA,COND.- SANITARY Y N
RECEIPT If
WORKMAN COMPENSATION DECLARATION }7)(T()RES,PER TRAP 0pe SCHOOLTAX Y N
E31 hereby affirm that I have a cem0,me of consent to self-Inmre,ora RE=- a
3500certiri1ate cate of)Worken'Compewtlon Insurance or a certified may thereof(Sec. GAS G.SYSTEM-1 INCA OUTLETS 3.08 PARKFEE -Y N
Pollcyp - 74? /✓9 Cam env _y.(aLr CcAs A.ss :M-o' eR a(EA)
RECEIPT
V
BUILDING DIVISION FEES
Certified cepyl.hereby furnished. IA
CREAPNCHECK FEE
[Cmfflcd roSE/INDUSTRL WASTE INTERCEPTOR
copy is with the city Inspection division. 13 0
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWERSANTTARY-STORM E.A.200FE Date - Re 10 a
(this section need not M completed It the permit Is(Drone hundred dollen
(81 I0)orlea0 WATER HEATER W/VENT/ELECTR ENERGYFEE - Y O
Icenetify thatoy in sahe p Pa..1.any..at,rformance ofthe so as to which
permit is blued, — 18S.
Q
I shall not employ say person in any manner m as to become subject to the WATER SYSTEM/TREATING - Q- ►
Workcn'Compensation Lews o(Callfomla.Date 3 s d� PAID S7, d(J
O Z Applicant NEW RESIDENTIAL PLMB. Dale
Z O NOTICE
ca MPLICAM:IL after makiompar ation pool Exemption,you `''Q'pT'
should ode,yo atforthwitect the ply wis'Compematlon provisloruofthe Labor TO L:
LU W Coda you at forthwith comply with each provislom orlhis perMtshall ba 1 LDINQ E
CL j deetrstl revoked. ,
CONSTRUCTION LENDING AC[NCY SEISMIC FEE
O. Thereby work for
rw them isacorstmnlon lending agency Cla. .) perform ELECTRIC FEE
Z anceof.the work!or whkh this perMtisIssued/see 3097,C1v.C.) TOTAL: �D0 a
LL O Lender's Name PLUMBING FEE . �
LL L) Lenmrapahatl QTY. MECHANICAL,PERMIT FEE MECHANICAL FEE s�
OW Icertl.Iagetocohave eadthisapplimtyndcutyordiaabovedMatead.aws
1 isrongtobgreeto complywlth all nd hereby authonereprcesand stat el awe PERMIT ISSUANCE -A7 FEE�$�ff� 6f 4�
} drysettoenteruldingcorutmctlon,andhereby property
pactionpurposo/thb - - r( �F�
F— Z tlly tocnleru 1Mabovementlorud property far Wptt[lon purposes. ALTER ORADD TO METH. �y Date Rfcei t�
t save,indemnity an d keep harmless the City of Cupertino - P
smtllabit ,7adgments,ro&e and expenses which may Inanywayaccrue AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL:Zga
alne ass C' In roneequence oftM anting of this permit.
d . A� AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
SSR re of Appllcent/ContactorO Data EXHAUSTHOOD(W/DUCq CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Illtheappllcant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCCfi IN
terial as defined by the Cupertino Municipal Cods,Chapter 933 and the
Health and Safety Code Section 25532(x)? HEATING UNIT(OVER 100,000 BTL) TOTAL:
RYes in No
lllthe applicant orfutun building occupant useegWpment or devicesVENTILATION FAN(SINGLE RESID) s� IC�pqyUAN DATE
whkheMthaurdousair conlaMnannasdefined 6l'the Bay AreaAlr T
_ M
Quality Management District? BOILER-COMP OHP OR 100,000 BTU)
'j Yea No
' ry •���q
• Thave nadtheh.Qusm tenalsrequimm nbunderChapier6.95of BOILER-COMP(OVER 100,000 BTU) AUG sl '1 1a7s7L
the GIffernla Health&Safety Code,Sections 25505,25533 and 25534.1
understand that if the building does not currently have a tenant,that it is my NEWRIESIDENTIALMECH. SQ.Fr ,
responsibility to not ify the occupant of the requirements which must be met /�
prior to Issuance of a Ccrtifira'te of Occupancy. 'CITY Ur LUrrri,�11s11140�'
Owner or authorlud agent , Data ISSUED Oy..-d-
TOTAL:
OFFICE COPY /