23526 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
building Project Identification PIRMITNO.
Budding Address: ^^r f")
16 '7,11Y2352
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J/yri. L V 0'w �� CITY OF CUPERTTNO-BUILDINGDIVISION
. Gono-ado eNamc: : APPLICATION /PERMIT
R�m� ELI SPEG BUILDINGaFJCTRICAL-PLUMBINGMECHAMCAL CATEGORY CONTROLArchitm/Engineer. :S4�G O wQTY _ ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrtss:_r Tot£ CGL., PERMITISSUANCE
LICENSED CONTR CTOR'S DECI hereby affirm that l am licensed under provblmenc APPLIANCESRESIDEM7AL ]OB DESCKIPIiON
ingwlth SC ion7000)of Dlvlsim3ofthe Businemand ProfeglonsCode,and my I
license ie to fail force• d offectC PANELS
License ClavLk-N �/
Date'—% y L ContractorUP TO 2DOAHM
ARCHITECTS DECLARATION 201-lM0AMP5
qqqq�+ceC I understand my plans shall be used as public remrde. OVER1000AMPSob
FF. $AREA �L 5/SQ.FT.
Licensed Professional SIGNSELECTRICAL ® � '\■
<6 w OWNER-BUILDER DECLARATION V
�n Fn SPECIAL CIRCNT/MLSC
F' 6 Iherebyaffirm SecoIn 7exempt/cointhe Contractor's License Law for the R
GOQ followingreason.tS aF7011$Businessand Pimp and Code:Anymyir E �/'- I • R i
OZ TEMP.MEI7'.R ORPOLE INST. AT L�
c.unty cture requltna permits.coowauirnsihea provgdemolbh,ororsuch mitto
any a signureprtorto emartehat he
requlmsuant t the provident
te TOWER DEVICES
' 1 Co a signed statement that he b licensed pursuant it the provisions f the
Ou, C.ntradors License Law(Clupter9(commencing with Section 7000).f Diel-
SWIMMING IDOL ELECTRIC VALUATION
F Og alon3 ofthe Business and Profesolom Code)orthat he b exempt themfromand M
S"N. the barb for the alleged exemption. Any t tola civil
of Section no res by any OUTLETSSWITCHFSFIXTURES
applicant fora permit ealleed exemption.
applicanttoSection not room than
m t] five hundred delta.($50
9, O. NEW KLSIDENIIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
.. ❑I,as owner will
the properly,or he employees with wages r thele dole
U7Q compensation,Business
andothe rk and Pmfouth.Code: heis et C.Mended or offeredLaw
$ O sale(Sec apply to alnow and f property
Code:The Contractors License law
S$ wonot applyssuch torn imserorthmu h who Wildnem orImproves videdttheme,at end OCC.GROUP RES.UNITS
whodaermnesa not
orwgh Msowne.If,ho s.eprwidMthatsuch
improvementsarcnot Intended earofco pletioee e.If, ownerep the
erwflbuilding have TO
improvement bsokl within one yearof compidion,the owner-budderwlll have
tryLLA+rcien of proving that he did not bund or improve for purpose of role.). QTY. PLUMBING PERMIT �FELJ L as owner of the property,am exclusively mntracung with licensed FLOODTDNE APN
contractors to construct the project(Sec.7044,Business and Pmicishtu Code: PERMIT ISSUANCEThe Contvaor's Limme Law does not apply to an owner d property whobuilds or Improves thereon,and who co norms for each jr,jem withALTER-DRAIN&YENT-WATER(EA)
actor(s)licensed pursuant to the Contractor'.License Law. FEE SUMMARY
7Sc am exempt under See B k P C for this reason BACK FLAW PROTECT.DEVICE OUTS113F FEES
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY. Y N
RECEQ'I'M
WOR"AN COMPENSATION DECLARATION p0(T( SPER TRAP SCHOOL TAX Y_ N_
yhemby af(Irm that I have a certificate of consent to xlt-Insure,or RECEIPT N
certificate ofWorkers'Compewtloolneurance or a certified ropythereofSec. GAS F.A.SYSTEM-1 INCA OUTLETS PARKFEE Y N
3800 1'011 ab CJ Pi = D 6 3 !S^ - RECEIPT#
Com an 7» ,Te^ bYL GAS F.A.SYSTEM-0VFRd(FA) BUILDING DIVISION FEES
[�certi(ied copy b hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE c
ertified copy b filed with the city Inspection division. r
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM F.A.20067 Date Recei t#
(Thbmdion need n.t be completed If the permit bfor om hundmd doliam
(SIM)ce leg.) WATERIIP.ALTIt w/VENT/ELECTR ENERGY FEE Y_ N_
I certify that in the performance of thework forwhlch this permit Is lasued,
I shall not employ any per In any manner eo g to become subject to the WATERSYSTEM/TREATING
Workers Compensation Tawe of California.Date PAID
O Z Applicant y NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
Z O NOTICETO APPLICANT.If,after making this Certificate of Exemption, ou
H W should became subject to the Workers
Compereatlon provisions ofthe Labor TOTAL: _
CCLU ; Code,you coast forthwith comply with such provisions or this permit shall be BUILDING «�
_ seemed by.ked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE L
CL Iherebyat(Irin that there b a cosutmdlon lending agency for the per(orrry T ELECTRIC FEE L L
D Z ance of the work for which this permit is Issued(Sec.3097,Civ.Cp ELECTRIC EEE �
0 O Icnder'n Name
H Lenders Address QTY. MECHANICAL PERMIT FEE
O W imrtifythat l have read this application and sumthatthe above information MECHANICAL FEE
bec—L.l agree to comply with all city and county ordinanonandetate laws PERMIT ISSUANCE r FEES PAID:
relating to building construction,and hereby authome,repmsentativee of this
(. city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
? (We)agree to save,indemnify an d keep harming the City of Cupertino Date Receipt#
V against liabilities,judgments,cogs and expenses which may in anywayaceme AIR HANDLING UNIT(TO I0,0D0 CFM) SUBTOTAL:
against sa ity In consequence of the p4,nti.g of this permit.
,T«(/[J/`�__ AIR HANDWM
NG UNIT(OVER IO,OOp CPM) CONSTRUCTION TAX
—LG_9, CONSTRUCTION TAX PAID:
Sigwt fApplicem/Contractor Date EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or Future build Ung occupant store or hand le hazardous HEATING UNIT(TO 100,000 BTU) Date Recel t#
material as defined by the Cu peri..Municipal Code,Chapter 9.12,and the -
f leallh and Sa(dy Code Section 25532(x)? HEATING UNIT(OVER 100,000 BTU) TOT
tL
Yes No
Will the applicant or tum building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Be,Area Air
Quality Ma ruigement Dist rid? BOILER-COMP OHP OR 100,DM BTU)
Yes No
havercad the has esus materials requlrerrcnb under Chapter6.95 of BOILER-COMP(OVER IM,0MJ BTU)
the Cali(omla Health&Szfety Code,Sections 25505,25S33 and 25534.1
understand that lithe building does not ecrently,have a tenant,that It Is my NEW RESIDEFITHAL MECH. SQ.FT.
resp.rc ibllity to notifythe occupant of the requirementswhich most be met
priors dance of a Certificate of Occupa acy. ^
ti 9 P�� 9d
Ow r rauthodud agent Data l ISSUEd� ,
OFFICE COPY