23308 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -:- USE BALL POINT PEN ONLY
Building Pm'ect IJemlllcatlon - PERhET NO.
tlullding Addme: L - 23308
a�• 9 re.
ams: ee A
cone . 2�j �� CITY OF CUPERTINO-BUILDI GDIVISION -
Contractor'•Name T ue.N .. APPLICATIO I P RMIT �r
I OWnGr
BUILDING-I➢,FCTRICAI BINC- CATEGORY CON7R{�!!11
.rchited/Engineer. Lic.Nee MECPIAMCAL.; `D
QiY ase
ELEC RI RMIT FEE BUILDING PERMIT INFO
Add."- �: 9 Ck /"?r PERMITISSUANCE �•
LICENSEDCONTRACTOR'SDECLARATION -
IberebyaffirmthatlamlicaaedunderprovisionsofChapter9(commnc APPLIANCFS NTIAL NJOB DESCRIPTIONint with Srctlon7000)ofDivisian3ofthe Bugnrmand ProfeasionsGade,and my ��
lnse Iain full foand affect. PANELS /
Licerm icen.Chm LION -
Date Contractor TMT
"ARCHITECTS DECLARATION20 is1'
007, I understand my piansshallbe used as public records.' V AMPS SQ.Fr.ILOORysARREA g/SQ.FT.
.. Z U I LECTRI
IY anxd Pro eml.ml ('le a1 1T,
OWNER-aUILDER DECLARATION SPl1IALCEIC T/
zs, � owing yafrm.Groton 703Impt(ro ossa Contractor's Llcenx law for �� y 16
Fgo qqq foliowingichreq(Sedlon7mttow nemandr,bpive Code:An d or W
cw.tywhlcpd.rt.it. mRtoro..q. th, .pU.tfe ..chorrctto 1P.MEC EI
q� a any swdure tatconolts leashes licensed
pursuant
than t the provision of t e /as
PJ s floe a actors statement that he t r9(.d pursuant it the provisions f the POWER DEVICES tWJ •_ '
G61 u,r Convadola License Law(Chapter9(commencing withSection xamptherefof Dlvl- ,VgNG 1Y)OL ECIRIC
OJ staixal the Bug.n.od .creti... Ayeilhathebemmpth=refromand _ VALUATION
the bash far a p alleged jcct the
Anyt tolacivi of Section not L5 by any alY
« applicanl(.ra permitsubjects the appilcanl loo dull penalty of not morethan �-E7SSWI $HXTIJRES tC/Ja
O
rfld,.d dllrs(5500). L
nralthe ro NEWRESIDEN77ALELIiCiR SQFr, STORIES / TYPECONSTRUCTION
p perty,or my employees with wage as lhelr soletion,will dothe work,and thednacture isnot intended or offered for
7064,Business and Professions Cade:The Contractors License Law
pply to an owner of property who builds or Improves t hereon,andOCC.GROIn' RES,17NIT$
s.chworkhi.UR th.ghhisownempi.y e,providMthat.0 h
Improvements are not Intended or offered for sale.If,however,the building or O'
Improvement issold within oneyearofcomplaioNtheowner-buBderwlil have '
tla.Burden alpmving that he did not build orimprove forpurpoaeofuleJ. QTY, PLUMBING PERMIT FEE FLOODZONE APN
Lj L as owner of the property,am exclusively contrading with licensed PERMIT ISSUANCE 1
contractors to cor,strod the project(Sec.7066,Business and Professions Code: L— s�
The Contractors License Law don nd apply to an owner of property who ALTFR-DRAIN&VENT-WATER(EA) •
Wolds or Improves thereon, and,who contracts for such ptojrcta with,a FEE SUMMARY
cgp)(actor(e)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
IJ I am exempt under Sec. B&P C for this crown
DRAINS FLOOR ROOF,ARECOND. SANITARY Y N
Owner DateA, .N
WORKMAN COMPENSATION DECLARATION
❑I hereby aIrl=that I have a certificate of consent to self-Imre,ora PER TRAP �• SCHOOL TAX RECEQ'P N
certl0ate.l Workeri ComprmaHonl—ranceoracedifledmpythereof(Sec. GAS EA.SYSTEM-1 WC.40U]LETS i—• PARK FEE Y N
3800,Lb CJ
Policy N REC=N
-- Com an GAS EA.SYSTEMAVFR 4(EA)
� Y BUILDING DIVISION FE I'S
Certlfled copy is hereby furnished.
cedmed copy V need with the city
lupectlon division. GREASE/INDUSfRL WASTE INTERCPLANCHECK FEE
ty , EPTOR. L� fA
CERTIFICATE OF EXEMPTION FROM WORKERS' iGREASETRAP , 1 PAID
COMPENSATION INSURANCE
(Thisxction need not be completed lithe permit bforonehundred dollars SEWER-SANITARY-STORM EA.2(IDFF. Date Recej
(s)ro)orlem.) WATER HEATERW/VENT/F3..ecrR ENERGYPEE Y-117—
1'�
D
I.nifythetinthepedomance.fthewarkforwMchthispermltialuued, _�� I L
label)not employ any person in any nvnner so m to become subjcct w the
W.ken'Compemmtonlawsof Cahfomia.Date WATIR SYSTCM/TREATING PAID
O Z Applicant Date Reeei t#
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ,Fr,
should become subject to the Workers'Compeuatlon provisions of the Tabor TOTAL:
~-W Code,you'must forthwith comply with such provisions orthb permit shall be BU
LU 9 deemed revoked. - '
O. p CONSTRUCTION LENDING AGENCY SEISMIC PC•E
Ihembyafftrm that there one comtmetion lending agency for the pedorm- ELECTRIC FEE a
M Z ance ofthe workfor which this permit is issued(5ec.3097,Civ.CJ T
U O Lender's Name PLUMBING FEE t
LL F Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Tanifythatlhavemadthsappllationand Yatethattheabovrinfor tit
d correct.I agree to complywith all cityand county ordinances and gate laws PERMIT ISSUANCE �/ FEES PAID:
>- V) relatingtobulldingrestrudlon,and herebyauthorbee representtiveaofthh
Z mebyto enterupon the abov=-mc Honed property for Inspection purpose.. ALTER OR ADD TO MECH.
(We)agree to save,indemnify an d keep harmless the City of Cupedin. Date Receipt#
V' against liabllitles,jrdgm.t,,coA..ed capon..which mayinenywayacome AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agalrut old City In con .Coco of lhr granting of ahb pr IL
AIR HANDLING UNIT(OVER 10,000CIM) CONSTRUCTION TAX
r �'SI tereof Applicant/Contractor' � E%HAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
Date Recei
tidal a.defined by the Cupertino Municipal Code,Chapter 9.17,and the
Healthand Sifaty Code Section75537(a)7 HFATINGUNIT(OVERI00,0008TU) TOT /l]
Ryesri No
Illlhe applicant orfuture bulldingoaupant use equipment ordevims VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hazardous atrcontaminants.,defined by/he Bay Area Air
Quality Maiagement Dlatrict7 BOILER-COMP(3LIPGR 100,000 BTU) f
4Yes No
havercadthebexa9uematerialsrequiretrentsunder Chapter 6.95of BOILER-COMP(OVIR100,000 BTU) (}}�� pp ,®
the Glifornla Health&Safety Code,Sediom2S505,25533and75534.'1 P A
mporsunderstanlltyto notithefy
building does of the nxpm avis which that it is my NEW RESIDENTIAL MECH. S'Q.R. V
mpr to issarc pari(ythe octe of Occup
a qulremenis which resat be semi APR 2O
"
prior to issuance ofa Certificate olOrvpanry.
Owner or authorised agent Date
TO IYH
OFFICE COPY