23905 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Projed Identification PEPWTNO.
Building Address: 23905
2Z 11;b V
iocr a Phone: A A
�AY> CITYOFCUPERTIN BUI NGDIVISIO A A
cono-a shame: LIc.No: APPLICATI N ERMIT V L L
Lam— CUA/J BUILDING.ELEGTRI A UMBING-M } CAL CATEGORY CONTROLM
Archit /Engl Lk.No:
'ifQTY EL IC PERMIT FEE
BUILDING PERMIT INFO
Address: NCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby ionaffirm 7000MElivgem3 fthe er Buiressa dPm ns Chapter9(cvmmmc CESRESIDE JOB DISCRQ�'IpN
ingwftlimmeh 1.Full force
Businnsand ProfesslonsCode,and my 0L 7-ft I a \fie j-'
Bceens Is In Full farce and erred. I 1 �I $� P W\Q Vr.�
Date Class LION -(
Date Contractor
ARCHITECPS DECLARATION 201-1000A
007 1 understand my plane shall be used as public mearda OVER 1000 SQ.FT.FLOOR AREA $/SQ.FT.
O SIGNS ELECTRICAL
Licensed Professional
6
OWNER-B NLDER DECLARATION SPECIALCRICUI LSC
Zt- Z I herebyaffirmthat l am exemptfromthe Contractor's License Law for the
fipo following reason.(Section 7031.5,Business and Professions Code:Any city or
rp muntywhlchmquiresaper ttommtmd,alteplmprove,demolbh,orrcpalr TEMP.ME APOLE INST.
�s.r any structure prior to its Issuance,also requires the applicant for such permit to )OWER CES
TE�ilil Bk a signed statement that he is licensed pursuant to the provisions of the
Contradoes License Law(Chapter 9(commencing with Section 7000)of Divi.
SWPOI�H Orn slon3ofthe Busasiness and Professlans Code)orthat he is exemptthere(romand NG POOL ELECTRIC �O�VALUA aAr.
X the bis for the alleged exemption. Any violation of Section 70315 by any ETSSWITCHESFIXTURES
a ppBcamforapermitsubie theappgcantioadAlpenaltyofnotmare t has
five hundred dollars(;500). NEW RESIDENTIALELECTR
I,as owner of the property, SOFT' STORIES TYPE CONSTRUCTION
p perry,ur my employes with wage as thele sole
compensation,wllldothe work andthe structure V not Intended or offered to
Oto(Sec.70K Bushsas and Pmfessluns Code:The Conlracto's Liame Law
�S$ docs not apply to an owner of property who builds or lmprovn thereon,and
OCC.GROUP RIS.UNITS
whodon such work himself or through his own employees,provided that such
Improvementsarenotintendedoro(feredfwule.If,howevegthebulldlnger TOTAL:
improvement s sold within oneyear°(completion,the owner-bullderwill have
o-LIiurden°tpro.ing that In,dice not bund or improve forpurpnaenf.k.). QTY. PLUMBING PERMIT FE
IJ L as owner of the property, exclusively tradin on licensed FLOOD ZONE APN
p pedy, Se. y eon g es PERMIT ISSUANCE
contractors eContrto construct the project(Sec.appy Business and Professions Code:
The Coor imptor es the Law don not apply to an owner I property who ALTER-DRAIN&VENT-WATER(EA)
builds o Improve thereon, and who contracts for such p ojects with a FEE SUMMARY
cunt lador(s)Ilrnnsed pursuant to the Contractor's License Law. BACKFIAWPROTECT.DEVICE
LI I am exempt under Sec. B&P C for this reason
DRAINS A,FLOOR,ROOF,ARECOND. NHARY Y N
Owner Date RECEII'TN
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCI{OOL TAX Y_ N_
F71 hereby affirm that I have•rnrtNcate of consent to selfdnsure,ora LEVE N
certificate m Workers'ComperuaB"nlrommore or a certified copy thereof(Sec. GAS EA.SYSTEM-I 1NC.p OUTLETS PARK FEE Y N
I
Mail,Lab C) RECEIPTNM
°]Icy N CAS G.SYSTEM-OVER 6(EA) BUILDING DIVISION FEES
996P-E,
sifqpedlfied copy b hereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANGHECK PEE
ertified copy b filed with the city Inspection division.
CERTIFICATE OF EXINIPPION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.SFT. Date Receipt#
(This section need not be completed If the permit V forone hundred dollars
($100)orless.) WATER HEATER W/VENT/E.ECTR ENERGY FEE Y— N_
1 certify that In the perfomunrnaf the work forwh ch thio permit is luued,
1 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 AppEant Date Recei t#
Z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENITAL PLMB. SQ.FT.
should become subjcd to the Worker'Compensation proWlons of the Labor TOTAL:
I/1 Code,you most forthwith comply with such provisions orthls pemNtshall be BUILDING FEE
W a deemed revoked.CONSTRUCTION LENDING AGENCY SEISMIC FEE 1
Q. I hereby afflrmthat there is a construction lendingagenry for the perform- TOTAL:
U ELECTRIC FEE
D Z ancooftheworkfor which this permit V isared(Sec.3097,Civ.C.)
O Lciulc.Name PLUMBING FEE
LL I- lander.Address QTY. MECHANICAL PERMIT FEE
O W IcedlfythAllwvercadthbapplicatlonandsiatethattheabovelntormanon MECI�ANICAL FEE
d la romed.Iagree to comply with all city and county ordinances and date laws PERMIT ISSUANCE FEES PAID:
relating tobullding com udlon,and hereby authorize mEm"'matives Of this
(_ N city to enter upon the above-mentioned Property for inspection punposn. ALTERORADDTOMECH.
Z (We)agree to save,indemnify an d keep harmless the City of Cupertino Date- Receipt#
V against liabilities,judgments,cogs and expenses whk maylnany v.y..e AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
'gabs' ty in ro °`" he gra"tin (t pennB. CONSTRUCTION TAX
s _ ^ AIRHANDLINGUNH(0VERIQ"CFM)
Signawreof lant/Coma r Da EXHAUST HOOD(W/DUCn CONSTRUCTION TAX PAID:
HAZARDOUSMATERIALSDISC S RE
Will thea plicant or future building ocevpant store andlehazardous HEATINGUMT(T0100,00011'M Date RQcci t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the --- —
Hnnh and SaretyCode Section 7S532(a)7 HEATING UNIT(OVER 100,000 BTI) TOTAL
Yn n No
Will the applicant"r(uturc building ocmpam use equipment ordevices VENTILATION FAN(SINGLE RE5ID) ISSUANCE DATE
which eMt hamnlous air contaminants as defined by the Bay Area Air
Quality Management Dist Hct? BOILER-COMP PHP OR 100000 BTI)
4Yn Nn � AB ®
havemla the
ealth& a requirements and 255rb.95 of BOILER-COMP(OVER I00,OW Ball)
thr�understand
dt at if th&Safety Code,not
25505,ve at nan,that. I
responsibility
that notifhe y
the occ does na ce require entswich that b iset NEW RISIUEIURTAL METH. ;Q.PI' JUL 21
rcsponsibnityce notifytheic to of of the requirements which most be met
prior to Issuance of a Certificate of Occupancy.
(I-IV ( ( U• _.tI IIVV
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE COPY