23659 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proeet Identification PERMIT NO.
Building Address: / 23659^(�r(�
/ CITY OFCUPERTI1AIUM
UILDING D ISION t�-G ltl l?/'^V� Vy
- cant ct a . Lk.No, APPLI AN /P IT
BUILDINGFJ, CMECHANICAL CATEGORY CONTROL X
Architect/ glneer. Lk.No:
QTY ETRICP FF FEE BUILDING PERMIT INFO
Address: PERMTI NCE '�� ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hth by Sedion7U )ofDi Bcen3ofthe under
usim lamnaoff h onsC(common
CES-RESIDE, JOB DESCRIPTION
Inensei in
force anDlWect. (the0usinessand Pro(caslonaCode,and
Ilcenx b In fait force and effect.
CI Lic
Date m h
'
Date Cormactor �
ARCHITECTS DECLARATION �" 701-1000AM
stZ I understand my plans shall be used as public records. OVER IOW SQ.FT.FLOOR AREA 8/9Q.FT.
O(�
CLicensed Professional SIGNSELFOTRICAL '
<wOWNER-BUILDER DECLARATION
SI'ECWLCIl2CUIT/M19C
(, IherebyalRrmthetlam exempt Contractor's License Lawlor the
7
following reason.(Section 7031.5,Huge.and Professions Code:Any city or �-+
TEMP.MEIT74OR['OLE IN5f. -
muntywhich requlmapermit romvtruat,alter,Mprove,demoWh,orrepalr
gmQa anystrocture priorte,Its lmuance,aborequires theapplicant forsuch permit to POWER DEVICES
6 r<a 6 file a signed statement that he is licensed pursuant to the provisions of the
�3t; Contonson's License Law(Chapter 9(commencing with Section 7000)of Divi. SWIMMING POOL ELECTRIC VALUA7Q
O sion3ofthe BusinesssndP .f .Code)orthmheiaexem themfromand II
< the basis for the alleged exemption. Any violation of Sectp1—/mo 70313 by any OUTLE7SSWITCHFSFIXTUR /���/\
O applicant for a permit subject m
the applicant to a civil penalty of not orethan �4„ 0'
ip five hundred dollars(E500). NEWRESIDENTIAL LECTlt
-- �I,as owner of the pmperty,or my employees with wages m their sole STOW rs TYPE CONS'IMUCTION
f,7¢ compensation,wBlda the work and thestmeture is not Intended or offered for
CaCC p sale(Sec.7044 Buslnem and Profembv Cade:The Contractors License Law
don not apply to anowner of property who builds or.riimproves thereon,and OCC GROUP RFS.UNITS
whodcessuchwo..Mm Bw Nrwgh Maownemmprovlded that such C1jlU
improvements are not Intended oroflered forsale.If,however,thebuilding or
improvement beold wit hinoneyearufcomp letion,the owner-buliderwillhatve
nofpmving that he did not build or improve forpurpose ofsale.). QTY. PLUMBING PERMIT FE
D LONE AI'N
L as owner of the property,am exclusively contracting with housed FLOO
ro
it ons tomnstruct the M
proj (Sec.7044,Business and Profesaloru Cods: PERMIT LSSIIANCE
The Con m6rb Limnos law does oct apply to an owner of property who ALTER-DRAIN VENT-WATER(EA)
Wilds or Improves Burger,and who contracts for such pW"with a
c I etr(s)licensed pursuant to the Contractors License Law. - FEE SUMMARY
f1 am exempt under Sec B&P C for this reason BACK FfAW OT Hi
Owner Date DRAINS FLOORRPDF,AREA,GOND. 1 - m [1� RY Y N_
RECEIPT X
WORKMAN COMPENSATION DECLARATION FIXTURES 7 / II LTA% Y_ N_
I
01 hereby affirm that I have a certi0rate of consent to self-Inure,ora i ` u RECEIPT X
certNmte of Workers Compensation Insurance or a certified copy thromf(Sec. GAS EA 5Y -ll 40U17.E1E P Y N
38W,Ub C.) I RECEIPT Is
I'oikyIf GAS EA.SY -OVERA(EA) aBU1LDING DIVISION FEES
Com any
�
Certlfled copy bhereby famished. GREASE/INDUSIRL WASTE INTERCEPTOR PI;ANCf ECK FEE
�Cmtifled copy b filed with the city inspection division.
CERTIFICATE OF E%EMPDON FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.700F1'. Date Recd tit
(rhlssection need net W completed tithe permit b forom hundred doliam
(S10))mInes.) WATER FIEATER w/VENT/ELECTR ENERGY FEE Y N
I certify that in it munm th work for which thio rnitls issued,
I hail cmplo y Ina y nner ec as WATER SYS1EAf/•IRGIING PAID
Workers Com if J?ptp of d D e C�
O Z Applicant v S NEW RESIDENTIAL PLMB. SQ.FT. Date ReCel t 1
Z O NOTICEc MPLICt tothea ermakinm a sationCertiflcate provi Exemption,you
should become subject to the workers'Compensation provatiov of the Labor TOTAL:
H N Code,you most forthwith comply with such providers orthb permit shall be BUILDINGFEE jam'
jdeemed revoked.
W _ CONSTRUCTION LENDING AGENCY SEISMIC FEE
a IherebyafOrmthat there Is a construction lending agency for the perform TOTAL: ELECTRIC FEE
M Z ante ofthe work for which that permit b Issued(Sec.3097,Civ.Q)
U O Icadera Name PLUMBING FEE
F lenders Addrem QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icertlfythatl have readthatapp0obonand state thattheabove information
a Is corect.I agree to comply with all cityand county,ordinances and state laws PERMIT ISSUANCE FEES PAID:
r relating to building construction,and hereby authorlu representatives of this
F city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH.
Z Date RfCCiPt4I
(We)agree to save,Indemnify an d keep harmless the City of Cupertino
V a g,Wthabilities' ndex enaeswhlch mny
ay inawayaccrue AIRHANDLING UNIT(170 I0,0)0CFM) SUBTOTAL:
agauat s ' 14 ° 1.permit r�
AIR HANDWNG UNIT(OVER 10,900 CFM) CONSTRUCTION TAX
Ig r Date E%HAus r HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZAR ISCLOSURE
Willtheapplica a,or futurebuil gocmpantstmnorhinllehazardcus HFATINGUNIT(TOIW,000BTU) Date Receipt OR
o material as defined by the Cupertln Municipal Code,Chapter 9.17,and the
Oc Ilcalth,and Safety Cade Section 755324)? HEATING UNIT(OVER 10D,000 BTU) TOTA
�Yv
MN. VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
\\ ,Will the applicant or(umrcbuilding occupant use equipment or devices
which cult hamolous air axotamlm u,as defined by the Bay Arca Air
Iity Management District? ROMER-COMP QHP OR IW,O(IO BTU) PAID
Yes OI�No a'G
Thave read the hazidous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
a the California Health&Safety Code,Sections 75505,75533 and 25534.I /)v .a
understandthatyto notify the ocgdoes not a rrcuirceents wench that it bury NEW RESIDENTIAL MEGA. SQ.Ff 'p'/'1/ 14 19OF
raponsibllity to notifythe ocmpant of the rryuvements which must be met /x
prior to Issuance of a Certificate of Ocavpancy. C11 Y Uf-
L(t` T)1
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE COPY