23629 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification 7 PERMIT NO.
Building Add reas: 23629
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Phone: A A
'5e- !a1—e—' �/GI(e—D7�3 CITY OF CUPERTINO-BUILDING DIVISION C—� ^
Contra .Name: Lic.No: APPLICATION / PERMIT ] (,
ones �� �3gD35 8U LDINGELECTR CALPLUMBING-MEC AMCAL CATEGORY CONTROL p
Arctdtect/Engineer. Lic.No:
qTv ELECTRICPERMIT FEE BUILDING PERMIT INFO
OU ��l PLUMB Mi�fi
Addresx CONTRACTOR'S
sp ❑ 11 ❑
LICENSED CONTeAOR'S DECLARATION
I hereby
action70that lamuoh3 ofhe under Buidessandof Cssiona9(coand nt-my APTLIAPANELS CESRESIDENTIAL JOB DESCRIPTION
Ingwlth Berton 7000)o(DiWsion3 oflhe8usinessand PrclessionsCode,and my
Brenna is m m snr and cited. 3_� PANELS L KOx1
Date Contractor `""j 701-1000 AMPS
ARCHITECPSDEC ON OVERI"AMPS SQ Fr.FLOOR AREA $/SQFT
a0 7 I understand my glare shall be used as publicublicm records.
WO SIGNSELECTRICAL
(1 6Licensed Professiansl
6. OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC
i., 7 Iherebyaffirce that am exempt from the Contractor's License Law for the
G H^ following reason.(Section 7031.5,Business and Professions Code:Any city or TEMP.MEIFR ORPOLE INST.
cmntywhichmquresaperMttocomtmd,altegimpmve,dennlish,ormpair
q��EE v anystructue priorto its issuance,also requlresthe appBontfor such permit to POWER DEVICES
E K U file a signed statement that he is licensed pursuant to the provisions of the
O w Contractor's License Law G (Chapter 9(romnencing with Section 7000)of Out-
SWIMMING R70L ELECTRIC
sioO the ba t for the essanalleged Professions Any)violation lsexem therefrom and VALUATION
G� the basis for the alleged exemption. Any violation of nahoof not m re any OU7LE.ISSWITCFR;SFDcTURFS 16 75 DO
Op appVrantfora permit subjects the applicant toadvll penalty of not more than r
Cv` five hundred dollars(5500). NEW RESIDENTIAL ELECTR
? ❑I,as owner of the roe SQ.FT. STORIES TYPECONSTRUCTION
property,rta or my employees with wages [herr sole
compensation,B.guewflldo thework andthestructurehe Commences
or iofferedfor
a�ap sale(Sec.704q Business and Professloru Code:The Contractole Liceme Law
tri $ does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RES.UMTS
who doessuchwork himselforthrough hlaown employees,provided thatsuch
improvements are not intended oraffered for sale.If,howeveq thrWilding or TOTAL:
improvement lssoldwithte oneyearofcompletion,the owner-builderwill have
th�a rden of proving that he did not build or Improve for purpose of sale J. QTY. PLUMBING PERMIT FEE FIAODTONE APN
IJ S as owner of the property,am exclusively=trading with licensed PERMIT ISSUANCE
metracmrs to construct the project(Sec.7044,Business and Professions Code:
The Contractor's License Law does nor apply to an owner of property who ALTER-DRAIN k VENT (FA)
Wilda or improves d
thereon, and who contends for such pWjes with a FEE SUMMARY
c,RI,ador(s)licensed pursuant to the Contractor's License Law. gpQ((p(pyy PROTECT.DEVICE
LJ I am exempt under Sec B 8c P C for this reason
CUTS I OF FEES
Owner Date DRAINS FLOOR,ROOF,AREA,COND. SANITARY RECEmT#
WORKMAN COMPENSATION DECLARATION FIXTURES-PER TRAP SCIi00L TAX Y_ N_
❑I hereby affirm that I have a certlRate of consent to self-Insure,ora RECEPT#
certifirgeofWorken'Compereation]vurance or a certified ropy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
38M lab C.)
Policy# 02/Ic 9 lG& — RECEB f a
GAS EA.SYSTEM-OVER 6(FA)
Co!any /c r r �wi ('� BUILDING DIVISION FEES
Certified copy ls hereby filed
the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE'
Q2crti(ied copy ls filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP'
PAID
COMPENSATION INSURANCE g�.Eg-SANITARY-STORM EA.200FC. Date Recef t#
(TMssedlon need not be completed if the permit Is for one hundred dollars
(8100)nrless.) WATER FIFATQt W/VEM/ELECTR ENERGY FEE Y_ N_
I mrtifythi t hi performanceof the work forwhich this pnrout Is lsstied,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers Compensation Laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recei [#
Z O NOTICE TO APPLICANT-.If,after making this Certificate of Exemption,you
should become subject m the Worken'Compensation provisions of the Labor TOTAL:
P N Code,you must forthwith comply with such provisions or this permit shall be ��
2 j deemed revoked. BUILDING FEE
(L — CONSTRUCTION LENDING AGENCY SEISMIC FEE
d ]hereby affirm
orkforthat then lsamret is use lending 097,agencyCiv.C.)
TOTAL: ELECTRICFEE
7 Z area of the work!orwhich this permit i----9ec.3097,Civ.CJ PLUMBING FEE
LL O Lenders Name
LL F tenders Address QTY. MECHANICAL PERMIT FEE tion MECHANICAL FEE
U land.Ithatl agree ,comp]ve mad with allcitlonanddc state thattheordina cess andInfor
alaws
0 W bcorred.Iagreeto complywith all city county and state laws PERMIT ISSUANCE FEES PAID:
U) relating to building construction,and humbyauthomee representatives ofthls
f W city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
Z (We)agree to save,Indemnify an d keep harmless the City of Cu pert[no Date Receipt#
V against liabilities,udgments,rosfsand expenses which may In any way accrue AIR HANDLING UMT ITO 10,000 CFM) SUBTOTAL:
against said City In consequence of the granting of this permit.
' AIR HANDLING(ATT(OVER t0,000CFM) CONSTRUCTION TAX
Signature of Applicant/Coetractor Applicant/ContractorDate EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the adefined by
the future ruin Municipal
hapten 9AZanrdos HEATING UMT(TO 100,000BTU) Dale RCCeI t#
Health
as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes In No
Will the applicant orfuture building occupant use equipment or devices VENTILATION FAN ISlNGLE RFSID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management Di❑strict'? BOILER-COMP OHP OR 100,0(10 BTU)
ye.
No
Ilovereadtheh. smaterials requirements under Chapter 6.95of BOILER-COMP(OVER 100,000 BN) 6/
the California I iealth A Safety Code,Sections 25505,25533 and 25534.1 �pp��
understand that lithe building does not currently have a tenant,that it vi my NEW RESIDENTIAL MECH. SQ.FT. °•'flas [.
responsibility to not ily the occupant of the requirements which must be met NAY 6 19(iy
? prior to vis a ceof Cc ificaw parry. JL
CIT, ," rCh vU
Owner or authorlud agent / Dat ISSUED BY:
TOTAL:
OFFICE COPY