23248 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PFR.MITNO.
Building Addrea,:
� O t. o K�a.� v a 23248
Phone ATR577 V=AA
CITYOF CUPERTINO-BUILDING DIVISION
contra rs Name: He.NO: APPLICATION / PERMIT
AArc t°d/Engineer. Lie.No: BUILDINGELECTRICALPLUMBINGMEC}IAMCAL CATEGORY CO
led—t1
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addma
PFRA9TISSUANCE 1:1 1:1 ❑
LICENSED CONTRACTOR'S DECLARATION
Iherecct[.raffirm that lam Rcenaefthunder B.provhlonaof Cha pter9( ,.m do AI'1'1lANCESRESIDENTIAl JOB DESCRN'HON
inense1Section 7(.anDie ffect (the8uainensand Profeaalona Code,and my
Bonne Is In full force end effect PANELS
License Clan Lich
Date Contractor UP TO 21
"
ARCHITECTAI IOWAMPS S DECLARATION OVER] AMPS
� v� 5/SQ.FT.
a0 0 I understand my plans shall be used as public records, ,
Fi Fj
Limmed Professional SIGNSELECTRICAL UTE R
<<�<� OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC CIM
17sp,�.-moi Iherebyaffirnthat l amexempt from the Comradoes License lawforthe /� ��
OOH❑❑ following reason. 70DS,Businessand Professions Code:Anydty or TEMP.METER OR TOLE INST.
P5 a county which mquiresa permit tocoetsud,alteq improve,demolish,oreepair
yS.ac DA
anyslmctum prior to its Issuance,also requires the applicant forsuch permit In
POWER DEVICES -
a0 U file a signed statement that he is Retnaed pursuant to the provisions of the
�3wG Contractors License Law(Chapter9(commsnMgwith Section 7")ofDivi. SWBAMINGPOOL ELECTRIC VALUATION
OGG sion3ofthe Businns and Professions Code)orthat heir exempttherefeemand
t✓ y.'Y the hist+for the alleged exemption. Any violation of Section 7031.5 by any
S ¢ OUTLETSSW[TC}{F&FI%'1"UIiES
applicant tons perMteubjectsthe appecant too dull penalty o(net marc than � I
five hundred dollans($50)). NEW RESIDENTIAL ELECTR
_ `.Q.FT. STORIES TYPE CONSTRUCTION
I,as owner of the property,or my employees with wages as their to
7¢
on it Business and
Prendthestrudumhn Contractor's
License
Law
❑ sale(Sec.7094,Business and Professlom Code:The Contractors Lletnse Law
jS$ docs not apply to an owner of property who builds or improves thereon,and OCC.GROUP RIS.UNITS
E whodoessuchwork hlmseUorthecugh hisown employees,provided thatsuch
Improvements are not Intended reoffered forsake.If,however,thebuilding or TOTAL:
improvement hsold within oncycamfmmpldiagtheowner-bu8derw111 have
as
of proving that he did not Wild or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LLLJ I,
s owner of the property,am exclusively contracting with Retuned PERMIT ISSUANCE
contractors to construct the project(Sec.7094,Business and Professions Code:
The Contractor's Wmme,Law don net apply to an owner of property who ALTER-DRAIN VENT-WATER(FA)
Wilda or Improves thereon, and who contracts fee such ptaje ts with a
,OST dor(,)urenxd pursuant to the Contractor's LicenseLaw. FEE SUMMARY
LJI am exempt under Sec B&P C for this mason BAIX FIAW PROTECT.DEVICEOUTSIDEIEES
DRAINS FLOORROOF,AREA,GOND. SANITARY Y N
• Owner Date RECEIPT If
WORKMAN COMPENSATION DECLARATION FIXTURES-PER TRAP SCHOOL TAX Y N
EC
❑I hemby affbm that I have a certificate of consent to adf-Insure,ora RECEIPT M
certificate of Workna'Compensation Insurance or a rertifled copythereof l5ec. GAS F.A.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,Lab C.)
RI:CIRI'f Is
Polirya CAS F.A. YSTCM-OVER
� BUILDING DI VISI FEE
mceanrty '
S
ified copy h hereby famished: GREASE/WDUSfRL WASTE INTERCEPTOR PLANCHECK FEE
❑CedBmd copy Is filed with the city inspection division. I 1D
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETAAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA.200FT. Date Receipt
(rhissedion need nd becrmp]OM If the permit h!.roue hundred dollen
(SIM).,I..) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N_
I certify that in the performance of the work forwhich this permit is Issued,
I shall not employ any person In any manner so m to become subject to the WATER SYSTEM/TREATING
WmIous Compematlon laws of Calforola.Date PAID
OZ Applicant NEW RESIDENTIALPLMRSQFT. Date Rotel t#
Z Q NOIICETO APPLICANT.If,after making this Certificate of Exemption,you
should become subject to the Workers'Compersatlon provisions of the Labor INITAU
V} Code,you most forthwith comply with such provisions or this permit shall be BUILDING as—
LEI
—W > deemed revoked.coNsrBUCTION LENDING AGENCY SEISMIC FEE
CL I herebyaffirmthat there hammtmdlon lendingagency forthe perform, TOTAL: ELECTRIC FEE
:) Z ance of the work for which this permit h issued tree.3097,Civ.c.)
(L O 1<nder',Name PLUMBING PEETY. MECHANICAL PERMIT FEE
LL L) Lender's Address Q MECHANICAL FE
OW ourect.Iagrctohave readthith allatynand dcuntyordinances einformation
IL iscoingt Wilding complywith all auhoo representatives
state laws PERMIT ISSUANCE FEES PAID:
r reytoenobu Pon to abov&construction, tyotlureprnenpurpos°(thio
(_ 2 city Wenteree to the above-mentioned property Wpe Cit purpose. ALTER OR ADD 70 MFOH. Date eeeipt#
(We)agree to nave,indemnify an d keep harmless the City of aysa no SU OTAL•
V
against liabilities,judgrrenb,cons and expennea which may In any way same AIR HANDLING UNIT(TO 10,000 CFM)
ag.l.vald City' re coca. he gra Ing of tis ape3t 1//—Y&
AIR IiANDLING UNIT(OVER 10,000C[M) CONSTRUCTION X
Sig tanto! ppllcam/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION T XPAID:
HAZARDOUS MATERIALS DISCLOSURE
Illthe apple..orfuture building occupant store or handle haearduus HEATING UNIT(TO 100,ODO BTU) Date R el t
material as defined by the Cupertlno Munldpal Code,Chapter 9.12,and the
IT®Rh and Safety Code ion 25532(a)7 HEATING UNIT 100,000 BTU) T TA
❑Yet °
Willtheapplicant or Sure building occupant use equipruent or devicn VFNTILAHON PAN(SINGLE NESID) ISSUANCE TE
which emit havardous air contamlmnts as defined by the Bay Area Air
Quality Management D's dl BOILER-COMP PHP OR 100,000 BTU)
4Ya �]�.J/'No V' W
haveread the haaa(Vousmaterials mqulmmrnbunder Chapter6.93of BOILER-COMP(OVER IN,000 BTU)
the California Health&Safety Code,Sections 25505,25533 and 25539.1 �yJpR 18
understa od that if the building doe,not currently have a tenant,that it is my NEW RESI DENIAL MECH. SQ.FT. 1992
raprrsibility,to ndify the ocavpant of the�mgqulmmenta which must be met vv
Prior to hsua ora rtitiateof Pa n
—7IA ' 3 fib' �IIY �Jr GurcntRxv
nor uthorlud agent Date )SgQpp BY
TOTAL:
OFFICE COPY