23682 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: 23682 3 6 8 2
10'750 rn0 ) �9p / G
�, e CITY OF CUPERTINO-BUILDING DIVISION r(_ Q p
L DAIL
ntr dors Name: I( ///��1 No:C APPLICATION / PERMIT `oa_� `2_
t o J BUILDING.Mr.CTRICAUPLLIMBING.MECHAMCAL CATEGORY CONTROL p
Areal e / Einer. Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
I'LAh
Address: PERMITISSUANCE o a ❑
LICENSED CONTR under rDECLA RATION
I hereby affirm that lam licensed under provisions ofChapter9(Dominent APPLIANCES-RESIDENTIAL JOB DFSCRBTION
ingwhhSection7000)ofDr,ision3of,t1he B�luslnessand ProfessionsCode,and my PANELS
/ )
lite
Lice s•ICNIA
(oamllk.p alr� '� /yyrE TrPTnWAhVS 201-1000 AM15 O� I/v ' a
Dat ConlraRor !!
ARCHITECPSDECLARATION OVER1000AMP5 5Q.FT.FLOOR AREA $/SQ.FT.
q�+re0 7O I understand my plain shall be used n public extends.
jX d(T Licensed Professional SIGNS ELECTRICAL
6 afaOWNER-BUILDER DECLARATION SPECIALCIRCUH/MISC
fo0owing reasseso
Ihembyrm that lam exempt fromthe Contractors License law for the
7p '� n.(Section 7131,5,Business and Professions Code:Any city or
TEMP.MEITdt OR POLE INST.
countywhich requimapermitroantrud,often improve,demolish,ormpalr
C1 a anyauucture priorto its issuance,also requireatheappliant for such permit to POWER DEVICES
a C U file a signed statement that he is licensed pursuant to the provislomu of the
3 ts� Contractor'sLicense Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
O slon 3 of the Business and Professions Code)or that he 6 exemptthercfromand
the basis for the alleged exemption. Any violation of Sectio7ML5 by any OUTLETSSWITCHFSFIXTVRPS
!y�$ aPplicantfora permit subjedstheapplicanttoa dull penalty of net more than 5e F Ja.�
P. fivchundreddollan(5500). NEW RESIDENTIAL ELECTRSTORIES
I,as owner of the property,or m employees with wages as their sole �'hT' 7YI'E CONSiRUCT'ION
C>Gcompensation,willdothworndthstructurrIsnot intenaelor offered for
5 p
is(Sec.7004,Business and Profession Code:rhe Contractor.License law
t,15$ does not applyto an ownerof property who Wildsor improvea lhamerx and OCG GROUT RES.UNITS
E. who dare such work himselforthraugh his own employees,provided that such
Improvements are not intended oroffered forsale.If,however,the building or TOTAL:
ineprovementtsaold whhinoneyearo(completiogeheowner-W Oderwiil have
t rden of proving that he did not build or improve for purpose ofsale.). QTY. PLUMBING PERMIT nFEE FLOOD ZONE APN
U L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE ,V
contractms to construct the project(Sec.7004 Business and Profession Code: V
The Ce'traders License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(FA)
Wilds or Improvesd
thereon,and who contracts for such ppojes with a FEE SUMMARY
cQ0llaetor(s)Ilanxd pursuant to the Contracior'sllanx law, BACK FLOW PROTECT.DEVICE
I!1 am exempt under Sec. B&P C for this ma.an
OUTSIDE FEES
DRAINS FIODIL ROOF,AREA,GOND. SANITARY Y_ N_
• Owner Date RFOEBT p
0�1<mWORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAX Y N_
y affirm that I have a artiBate of consent to self-insure,ora RFCEErf M
artlficateof WorkeraCompensation lnunnaara artBled copy themof(See. GAS FA.SYSITM-1 WCAOUILE15 PARK FEE Y N
3800, # 1'7-9333()-92. RECEIPT PolicyRECEIPT p Com .cy I N GAS G.SYSTEM-OVER4CEA) BUILDING DIVISION FEES
[Certed ropy Is hereby furnished. GREASE/INDUSfRL WASTE INTERCEPTOR PLANCHECK FEE
e"ud copy is filed with the city inspection dNfiti.n.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-S[ORM EA 20OFT Dale Rewi t#
(This section need net be completed If the permit is for one hundred dollars
(SIM)or testi WATER HEATER W/VFN'T/ETRCTR ENERGYFEE Y_ N_
I artily that in the performance of the work forwhich this permit is tsaed,
I shall not employ any person In any manner so as to become subject to the WATER SYSILM/TREATING PAID
Workers'Compensation la.vs of Cali(ornb.Data O Z Applicant NEW RESIDENTIAL"B. SQFf. Date Recei t#
Z O NOTICETO APPLICANT.If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
CC UI Code,you mus:forthwith comply with such provisions or this permit shall W BUILDING
CL j deemed revoked.CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL C thereby affirenthat there is a construction lending agency for the perform- TOTAL: ELECTRIC FEE
area a fthe work for which this permit is issued(Sec.3097,CIv.G
02 Leaders Name PLUMBING FEB
IL F Lenders Address QTY I MECHANICAL PERMIT FEE MECHANICAL FEE
U 1cartifylhat l have read thisappliation and statethattheaboveinformation
O W iscorreci.I agree to comply with all city and county ordinances and state laws PFRMITISSUANCE FEES PAID:
IL misting to building comtactian,and hereby authorize representativn of this
F— U) city to enter upon the above-mentioned property fee Inspection pu rposes. ALMORADDT0MECH.
(We)agree to save,Indemnify an d keep harmless the City of Cu pretax, Date Receipt#
V ugainst liabilities,judgmenb,.9,spo expenses which may in any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
again yin rynaequence a ti gofthl.pennit
Ce/% (/J/1 W, 5 AIR HANDLING IMI'C(OVER IO,000 CFM7 CONSTRUCTION TAX
Sign urcof Applin /Contractor Date allAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
2ARDOUS MATERIALS DISCLOSURE
Wllltheappllant or future building occupant store or handle haeardous HEATING UNTT(TOIc,O(HIHJ) Date Recei t#
meterhl as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I lea th and Safety Code SMion 25532(a)T HEATING UNIT(OVER 100,00 BTU TOTAL: 1715-0-
❑ Y. ri No
Will the applicant or future Wilding occupant..equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which colt hazardous air comaminnte as defined by me Bay Area Air pp
. Quality Management District'! BOILER-COMPOFTI'OR 100,000 BTU � P'aI
Y:s n No
have read the haxa-r7ous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTV)
the California Health&Safety Code,Sections 25505,25533 and 25534. 1
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FI'. 1�T
rmponsibilitym ndify the occupant of thn requirement.which must be mot ,n
prior to Issuance of a Certificate ofOmpancy. rill uF 'VUt
Ownermauthmim,1.gent Date TOTAL, ISSUEDBY:
OFFICE COPY