23191 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: 23191
neva arae: a one: q A
leiµ l Q Q CITY OFCUPERTINO-BUILDING DIVISION
Con 's Name: Lie.No: APPLICATION /PERMIT
AIp
BUILDI NGELECTRICA6NPLUMBING- ECFfAMCAL CATEGORY CON"pR)
Amchited/Fsgineer. Lic.N. �a 11741
QiY ELECTR P MIT FEE BUILDING PERMIT INFO
Address: PERMITISSUAN / ❑ 11LICENSED CONTRACTOR'S DECLARATION
1z y I hereby affirmthatlam Bcrosedunderprovtsionsof Chapter9(mmmen _APPUANaU6DENnAi. OB DE 1411110N
ingwith Sccdon7000)of Dlvbicn3 ofthe Businessand Profesalons Code,and my
license Is In full force and diet
Llaenx Claa
Date__Contractor
2011000
ARCHIHITECICI PS DECLARATION
7 ]understand my plans shall be used as public records OVERT ? S SQ.Fr.FLOOR AREA S/a/SQ.PF.
}i Z Licensed Professiarul SIGNSEL AL
<6 OWNER-BUILDER DECLARATION
to E1 SPEC 14CUITaTISC ,a
F. 7 Iwbeg alffirenthmson.(ect Iaion 70313,exempt from the d Professions
License Law cotton
InflocmntywhichmquimsaperQt$Rminess m"t Profemionae=lehnycity ormpair P.MEfQt ORIOLE INSf.
fil cwntmmmpqulresabmame,alsomct,a)teheopbvnifmollah,orrepto
any atsudurc statement
that
he Is atso sed pursuant
t the forauchpermit e
POWER DEVICES
s� Cie a signed statement that he ts licensed pursuant it the prowmru of the
pOw� Contractor's License Law(Chapter9(ronvrendng with Section 7000)of Di - SWIMMING IDOL ELECTRIC
W 30 slon3ofthe Burnmessand Profeselom Cede)orthat hats exempttherefremand VALUATION w
Y.'S the basis for the alleged exemption. Any violation of Sectio70015 by any (_tel l/a,CaL
OUTLETSSWITCIiESFlXTURFS 6 P7
�fiapplicant for a permit subjeRsthe applicant too dull penalty of not more than 1
- j�vejp drcd dollars(5500). NEW RESIDENTIAL ELECTR SQFE. STORIES TYPECONSTRUCTION'
7 as owmr o!the property,or my employees with wages as their sole
c ansation,will clothe work and thestructure Is not Intended or offered for
Osale-(Sec.7IM6,Business and Prafezaiona Cade:The Contraclora Llcerue law
j$ don not apply to an owner of property who Wilds or improves thereon,and OCC.GROUP RFS.UNITS
whod0nsuchwork himself orthroagh hisownemployees,provided that such
Improvements arc not Intended orof/ered forsale.If,however,thebulldingor TOT
impeuvementtsanld withinoneyearofcompletb theowner-WBderwill have
If urden of preving that he did not build or improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
u I,as owner of the property,am exclusively contracting with IkensM PERMIT ISSUANCE
contractors to ronstrud the project(Sec.70K Business and Profindiaru Code:
The Commences License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER
Wilds or Improves thereon,and who contracts for such p(ojeds with a
c FEE SUMMARY
ntractor(e)Ilcensed pursuant to the Contractors Llmnx Law.
L�I am exempt under Sec. B& P C for this mason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N_
4W Owner Date m SCHOOL TAX Y N
a RECEIPT N
WORKMAN COMPENSATION DECLARATION FIX.IlIRES-I'ER•I.RAI'
❑1 hereby affirm that I have a certllicete of consent to aeR-insarc RECEBT N
ccnlfiateofWarkan Comperuation Insurance ora certllled mpythemaf(Sec. GAS EA.SYSEM4 INCAOUILEIS PARK FEE Y N
3800,lab C.) RECE[IT a
Policy N
CGAS EA.SYSFFM-OVER d(EA) BUILDING DIVISION FEES
om Cany enlfied ropy he hereby furnished. INTERCEPTOR PLANCHECKFEE /�
nCenified ropy Is filed WASTE filed with the city Inspection division. 1`O
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PA� ////���� N
COMPENSATION INSURANCE SEWER-SAMTARY-SNRM EA 2(pF7 a e Re i t#
(fhb retna need not be completed If the permit is forom hundred dollars
($100)orlem.) WATER HEATER W/VFM/17.FCTR ENERGY FEE Y_ N
m _
I certify that In the perfoanceof the work forwhich this pemb isdt sued,
I shall not employ any person to any manner eo as to become subject to the WATER SYS //TREATING s
Workers'Compensation Laws of California.Dae PAID
0Z Applicant NEW RESIDENTIAL PLMB. SQ}7. Dale Recei t#
Z O NOTICE TO APMICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Compenzation provisions of the Labor TOTAL:
F yCode,you=at forthwith comply with such provisions orthts permit shall be BUILDING ••E
W j deemed revoked.
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE
Q. I hereby affirm that there is a mmtmdion lending agency for the pekorne ELECTRIC FEE
D Z ance ofthe workforwhichthts permit d issued(Sec.3097,CIv.C.) TOTAL:
02 leederb Name PLUMBING FEE
LL H I.cnder'a Address QTY. MECHANICAL PERMIT FEE MECHANICALFEE
U I certlfythat l have read this application and date thatthe above Information .�"
0 W is comes.Iagree to comply with all city and county ordinanocsand are laws PERMTILSSUANCE FEES PAID:
r d relating to building construction,and hereby authorize representatives of this
(_ N dty to enter upon the above,mentioned pmNrty for Inspection purposes. ALTERORADDTOMECH.
? (We)agree to save,IndemNly an d keep harmless the City of Cupertino Date Receipt#
V against liabilities,pdgments,mks and expenses which may In any way accrue AIR HA LADLING UNIT ITO 10,000 CFM) SUBTOTAL:
V a id City In mnaequence of the granting of this permit.In ronaequence of the granting of this permnit.
AIR HANDLING UNIT(OVER 10,000 CIM) CONSTRUCTION TAX
si tura of Applic nt/Contractor Date EXHAUST HOOD M/DUCT) CONSTRUCTION TAX PAID:
HAZA R DOLS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or ha rd le hazardous HEATING UNIT(TO 100,000 BTU) Date Reeei t
material as defined by the Cuperti no Mu nicipal Code,Chapter 9.12,and the -U A
Health and SafetyCederr�Samon25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOT L. („(,J
❑Yea u No
Will the applicant orfutvm building occupant use equipment or devices VEN"DLATION FAN(SINGLE RESID) ISSUANCE DATE
which emit harzndous air contaminants..defined byted Bay Arca At, p� p
pr,
Quality Management District? BORER-COMP QHPOR 100,000 BTU) R1 I D
j Yes (7 No
have read the haza nus materialsrequirementsunder Chapter 6.95 of BORER-COMP(OVER 100,000BTU) FEB a] 1�J7 nz
the California Health&Safety Code,Sections 75505,25533 and 25536. I 199
understand that ifthe building don nolmrrently have a tenant that it is my N'EWRFSIDENTIALMECH, SQ.FT. Y
roporuibility to ratify the occupant of the requirements which must be met
prior to issuance cd a Certificate of 0empancy. CITY Uf cuptti I IIVU
Owner or aulhoriud agent Data ' ISSUEDBYt--
OFFICE COPY