23229 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT'PEN ONLY
Building Proed Identification PERMIT NO.
Building A'LL _ c ' - - 23229
Z �-
Owner aces: e. A
on 191� �.p� CITY OF CUPERTINO-BUILDING DIVISION 11 .-� p� -
Contractor's Name LIc.No: APPLICATION /PE MIT' l �Z Z
w BUILDINGELECTRICAI.PLUM INGFIAMCAL CATEGORY CONTROL N
Architect/Englmer. Lk.No:
QTY ELECJRI P RMFF FE BUILDING PERMIT INFO
Address: PERMITISS N
LICENSED CONTRACTOR'S DECLARATION 0
]hereby affirm that l am licensed under provisions of Chapter9(comment, APT N RESIDENTIAL ]OBD RI'DON
licameh I.f.1170007of Dlvlalan3o(lhe0usinenand ProlnalonsCode,an D�rIL — —
[igeitS tuBformandeffeR.' f��'�• GSC TJPHOu1
License CLss Ltc.N -
.Date Contrador - M
ARCHITECPS DECLARATION 201-1000 �.JV
Qµ rO. plans.
hall understand my plhall be used as public records. OVER100 SQ.FT.FLOOR AREA SQ.FT.
E ll Licensed ProtenWnal - SIGNSE
<N - OWNER-BUILDER DECLARATION
W.�4 I hereby affirm that lam exempt fromthe Contractor'sLlmnse Law for the gpp-CIACULT/M '
SSjj p following reason.(Station 7031.5,Business and Professions Code:Any city or P
F� construct,county which requires a permit to conuct,alter,Improve,demolish,or repair
q G .a a ny.tm=mpeortolhs mame,alsomquirestheappliantforsuchpermitto
l5 O file a signed statement that he b licensed pursuant to the provisions of the )
Q6 u, Contradori License Law(Chapter 9(commencing with Section 7000)of Dlvl
elon3ofthe Business and Professions Code)or that he exempt therefrom and B POOL`EpLECTRIC VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any. S�I�F'1F1 �+
G appErantfare permit subjecia the applicant to a civil penalty of nae name than OUTLET
five hundred dollars($500). IGNEW RESIDENTIAL ELECTR SQFT, STORIES TYPE CONSTRUCTION
I,as owns of the property,or my employees with wages r there sole
compensation,wilBusinthe ess
and k,and the strodureh Contractorme or d for
Lau, -
QO saldoe(Sec. ppy Business and f property
Code:The or improves
License Law
does noossuch torn owner otproughhis o builds wnor improovided that and OCC.GROUP, RES.UMTS
whodoementswork time Intended
oroffe h dorsal.If,ho employees,p however,
building or
improvements wldwintendedoroofcreplekmthe meraeglhebuildingw 70TAL: -
ImprovemenUseoldwlthlnors)earo(compldbn,tbeowner-WBderwill have '
enofprovingthathedid not build or improve for purpose o(sale.). QrY, PLUMBING PERMIT FEE FLOODZDNE' APN
as
owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
raatow to construct the project(Sec.704y rons Business and PfessioCode:
The Contractor's License Law does nae apply to an owner a(property who ALTER-DRAIN&VENTWATER(EA)
Wilda or Improves thereon, and who contracts far such ptojmts with a -
onactor(a)licensed pursuant to the Cormadar's License Law, FEE SUMMARY
BACK FLOW PROTECT.DEVICE
u I am exempt under Sec. B&P C for this reason
OUTS I DE FEE 5
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY- -Y N
Date RECEIPT#
WORK MAN COMPENSATION DECLARATION -
QI hereby affirm that I have a cewFIXTURES PER TRAP SCHOOL TAXY N—
rtlBrate of consent to self-hu
ram,or BBC=#
certificate ofWorkers'Compensation Laurance or a certified copy thereof(Sec. GAS FA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,Lab
Policy# - _ - RECEB'T X
Cam any GAS FA.SYSTEM-OVER4 LEA) BUILDING DIVISION FEES
[3 Certified copy is(]led withh the city
Inspection division.e
Certified copy is hereby famished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE
hty
l
CERTIFICATEMPE SATION NS FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA IWRI, Da[e Recei [ b N
(This section need not be completed if the penNt L foram hundred dollars
($100)wfy that
WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
]certify(hath any person In any
mar
er an as to becola me
permit ct to the —
I Whale not employ any person In any manner se n to become eubfeat to the WATER SYSTEM/TREATING '
Workers Compensation Laws of Ull(omla.Date PAIDO Z Applicant
Z Q NOTICETO APPLICANT:1LaNer ma king this Carlkate of Exemption,you. NEW RESIDENTIAL PLMB. SQ.FT. Date Re
shouldbmmnubjcttothe Worken'Compematlon provLlonsafthe Labor
y Code,you must forthwith comply withauch provisionamthls perrnitshall be NG •H
j deemed revoked.
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
O. I hereby sf0rmthat there is a construction lending agency for the perform- ELECTRIC FEE
7 Z ance ofthe work for which this permit l9 b.ued(Sec.3097,Civ.C.) TOTAL. ELECTRIC EEE
V O tender's Name -
u. F- Lender'.Addrea, QTY, MECHANICAL PERMIT FEE MECHANICAL FEE
O W Iredily thatl have read this application and atate that the above Information
1 iscorreat.I agreeto comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. W relatingtobuildingmmtmctI. dherebyauthorlaerepresentaBveso(this
F Z cdytoenteruponthe abova n nad property.for Inspection purpose.. ALTERORADDTOMECH. DRI. RCCe1Pf#
— (We)agree n ,Inde an d keep harmless the City of Cupertino -
againstliabl ea,' a expenseswMchmay)nanyw yaccme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against saCI gr thea Pe it. -
Q?/ AIRHANDLING=(OVER 10,000CFM) CONSTRUCTION TAX
Ig a reo(A Flit nt/Contractor ate EXHAUST HOOD(W/DL'C'D CONSTRUCTION TAX PAID'
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BHI) - DRI.. Recti t![ l
'material as defined by the Cupertino Municipal Code,Chapter 9.12 and the
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) - TO
QYee No
Will the applicant or wmbulldingo pantumequlpmentordevims VENTILATION FAN(SINGLE RESID), $gANCE DATE
which cant hazardous air contaminants as defined by the Bay Area Air AA tltl A!
Qua lily Management District? BOILER-COMP(3HP OR 100,000 BTU?
4Yea n No
havxrmdthehaza�ouamaterialsrequirements underChapter6.95of . BOILER-COMP(OVER IW,000 BTU) �Q� �g X992
the GlBumla Health&Safety Code,Sections 25505,25533 and 25534.1
understa od that if the building does not currently have a tenant,that It b my NEW RESIDENTIAL MECH. SQ.FT
responsibility to notify the occupant of the requirements which must be man C�11 Q
prior to Issuance of.CertitiwteofOaupaocy. CITY F CUPLI'IIPd:IY{/�
Owner or authorized agent Data ISSUED BY:
TOTAL:
OFFICE COPY