23881 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification -PERMIT NO.
Building Address: 23881
•f sera erre: one:
C L,I CITY OF CUPERTINO-BUILDING DIVISION
conlracinis Nama: S Lk.N9: APPLICATION I PERMIT 7'R
BUILDINGELFCTWCALPLUMBING-MECHAMCAL CATEGORY CONTROLN
• Amhlten/En n �— Lie.No: -
QTY ELECTRIC PERMTT FEE BUILDING PERMIT INFO
Address PERAIITISSUANCE
LICENSEDCONTRACTOR'S DECLARATION . t—a�
I hereby affirm that l am licensed under provisions of Chapter9(exmenam APPLIANCFSRESTDENFIAL JOB DESCRIPTION
Ingwllh5I f 117000)u(DiWfect. (the Buslvuand Pro/eeslaneCode,and my a xs.•u erg C'
I icense Is In fl1f and effect.N C�-rx PANEIS L `(/�<vF♦r/a,
License V Llc p V
Date Contractor �L" UP TO 2DO A
ARCHITE URA 1 N 701-IOW AMPS
reO Zp to Brits mypbvehaB upubBcmcorde. OVERIOWAMPS SQ.FF.FLOOR AREA S/`SQ.FL
Licensed Professional SIGNS ELECTRICAL
«< OWNER- DER DECLARATION
{n SI'EC7AL CIRCUIT/M15C
owing axon.(Sullamexempt fromil and orsLicen
law forthe
following which
req unstop permit
to7031S,Business and Professions Code:Any city it
O F�y9 TEMP.METER OR POLE INST.
�� � county requbesapernitto rovtroci,niter,improve,demolish,S any structure prior to its issuance,also requires the applicant for such permit to POWER DEVICES
RJ V Ne a signed statement that he is licensed pursuant to the provisions of the
FQj 3µ Contractor's Lkeve law IChipler 9(mmmendng with Sedlon 7000)of Divl-
�OS ;ion3ofthe Bustnessand ProfesslovCode)mthat he b exempt therefromand SWIMMING POOL ELECTING /A VALUATIgN.-
Q the basis for the alleged exemption. Any violation of Sock 70715 by any UILETSSWITCHESFIXTURES !� O/lIa (a(�
applicant for a permit subjects the applkantto a civil penalty of not rrore than l9 v�C..11s
five hundred dollen(5500).
L cue ower of me property, NEW RESIDENTIAL ELECTR Ft.
�n ❑ p perry,or my employees with wages as their sok STORIES TYPE CONSTRUCTION
rompennation,willdolhe work andthe structure Is not Intended or offered for
C O sale(Sec 70K Business and Professions Code:The Contraaor's License Lw
$ does not apply to an owner ofproperty who builds or improves thereon,and
^ who does suchwork himself I through his own employees,provided that such OCC.GROIIP RFS.UMTS
Improvements are not Intended or offered for sale.If,however,the building or
Improvement hsold within oneyearofcomplelbn,the owner-builderwill have
tbiLli+rdenofproving that he did am build or improve for purposeofsale.). QTY. PLUMBING PERMIT FEE
L j L as owner of the property,am exclusively contracting with licensed FLOOD ZONE APN
contractors to construct the projet(Sm 706/,Business ami Notation.Code: PERMIT ISSUANCE �•
The Contraciai s License Lw does not apply to an owner of property who ALTER-DRAIN&VFM-
bu0ds or Improves thereos,and who contracts fee such ptojecu with a WAS(EW
C�p([mtor(s)Emitted pursuant to the Contractor's Licenss Law, BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B k P C for this reason
• Owner - Date DRAINS fl.ODR ROOF,AREA,GOND. SANITARY Y_ N—_
WORINIAN COMPENSATION DECLARATION RECERPf
❑[here SOBOOL TAX Y N M
by affirm that I have a msmtiBcate of consent to self-Insure,or a F1XTTlRES PER TRAP
certificate of Workers'Compevatlonlvuraner ora cerdard copythercuf(Sec: RECEIPT N
3800,Lab C.) 1 ( CAS EA SY 1 PARKFEE Y— N
Policy N o RECEIPT N
Cooany GAS U•$1' a r^ .BUILDING DI VISION FIGS
Codified copy is hereby furnished. GREASE/w L iDRj PLANCHECK FEE
C] ed copy b filed with the city Inspection division.
CERTIFICATE OF EKEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEINER-SA P Date Recei tW
eed
(this section nnot be completed If the permit Is fora.hundred dolls -
alMorleea') WATER HEATER w/VENT/ELEC7R ENERGY FEE Y N
I certify that In the performance of the work for which this permit Is luded, —
I shall not employ any person in any manner em as to become subject to the WATER SYSTEM/TREATING
Workem'Compersatlon laws of California.Date ER PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQFF. Date Recef tq
Z NOTICE TO APPLICANT:III nuking this Certificate of Exemption,you
should become subject to the Workers'Compensation pro,blons ofthe Labor - TOTAL:
N Code,you=at forthwith comply with such provisions or this permit shall be '
W Gems derevoked. BUILDING
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 herebyaf(Irmthatthere b a rovWRlon lending egcruy for tM perform ELECTRIC FEE
D Z an¢ufthe workforwhlch this permit b lssud(Sm.3097,CIv.C.) ��
Leefa Name
LL d
1= Lender.Addreas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U Icedl"atlhavereadthbapphUtbnandmtethaitheabovelnformatlon
O W Iscorren.I agreeto comply with all city and muntyordinancesand elate lawsPFRMRISSUANCE •� FEES PAID:
} 1 relating to building mnatruaton,and herebyauthorUa ropresentmivesofthb
H N city to enter upon the abovo�meniloned property for Inspection purposes.. ALTER OR ADD TO MECH.
? (We)agree to save,Indemnify an it keep harmless the City of Cu pedino Date Receipt#
V against lhbWUcs,jidgments,mets and expenses which may In anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) ' SUBTOTAL:
net uld City in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER Io,=CFM) CONSTRUCTION TAX
signet co ApplIcanl/Contractor Data EXHAUST HOOD(W/DUCT) ,� CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE _
WllltheappBv rat or future building occupantsram
ore or handle hadous HEATING UNIT(TO 100,000 BTU)
material a a defined by the Cupertino Municipal Code,Chapter 9.l;and the Date Recei
Health and Safety Code Section 75532(a)7 HEATING UNIT(OVER 100,000 BTU) TO 5
❑Yes No
Will the applicant or tore building occupant use equipment or devices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which emit haardous air contaminants as cleared by the Bay Area Air p
Quality Management District? BOILER-COMP OHP OR 100,000 BTU) _ ' D
[?Yes ❑❑No WW
have read the hazardous materials requirements under Chapter6.95 of BOTLER-COMP(OVER IDg000 BTU)
the California health k Safety Code,Sections 75505,75533 and 25536.I p' 2 2, 1992
understand that lithe building does not currently a
have a tenant,that It b my NEW RESIDENTIAL MECH. .FI'
responsibilitySQ •��1�
ponsibility to notify the occupant of the regWmments which must be met �V
prior to issuance of a Certificate of Occupancy.
u "
Owner or authorized agent Data ISSUED BY:
OFFICE COPY