23118 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Bollding Address: 2 3118
10q4 ? ERR( R0
hers ossa: ryFhone APPLICArUT9UWnTAM=
L4VOV CITY OF CUPERTINO-BUILDING DIVISION
• Col-Roe'• Lic.No: APPLICATION /PERMIT L "2-3797
BUILDING-ELECTRICAI,PLUMBING ME HANICAL CATEGORY CONTROL X
Architect/Engineer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PIXh4TISSUANCE ❑ ❑ ® ❑
LICENSED I CONTRACTOR'SunderDECLARATION
I hereby affirm thatlam Licensed under provisions of Chapter9(mmmenc APPLIANCES-RESIDENTIAL JOB DESCRE'TiON
Ingwith Section7000)m Divlcicn3 ofthe Businesad ProfemlonsCode,and my
PANE
license is In full( dfett. ^^ 'a LS
License Chm�' Cn Liea Or�� 7Sn�� W
Date Contractor i
-1-�' YU ARCHITECT'S DECLARATION 2014000AMIS
Wz Iunderotand my plans shall be used sspublicrecoNs. OVERIODOAMPS SQ.Fr.FLOOR AREA $/SQ.FT.
MLicensed Professional SIGNSELECTRICAL
OWNER-BUILDER DECLARATION
�n E7 SPECIAL CIRCUIT/MLSC
pp, � Thereby afRrmthatlamexempm
frothe Contractor's License lawfor the
OgF� followiregrexam.(Sect1on70T1.5,Business and Professions Code:Any city or TEMP MEEK OR POLE INST.
county which requiersa permit tommtruct,alter,improve,demolish,oreepair
F 1�,�,,JJ anystrutture priorto Its Issuance,aLaorequira lheappllcant forsuch permit to POWERDEVICES
C 0 file a signed statement that he is licensed pursuant to the provieloru of the
Oaf Contractor's License Law(Chapter 9(mmmencing with Section 70W)of Owl. SWIMMING POOL ELECTRIC
30 AIM oflhe Bosons and Pmfemiom Code)mthat he beumpt therefromand VALUATION
Q 5_ the basis for the alorge!exemption. My violation of Section 7031.5 by any
zppBantforaper tsubjetstheapplicanttaadvilpewltydnan moan OUTLETSSWITCHESHXTURPS
Og five hundred delta.(S500). NEW RESID[N77AL ELECTR SQ.FT. STORIES TYIT CONSTRUCTION
I,os owner ll the property,or my employees with wages thele door
com(See 7 om,But clothe ass and work,fasiond strude:s is The or IntendedContractor or License
dfor
Law
N5 F O sale(Sec appy Business and f property Cade:The or Improves Liceve Gw
PR don not apply torn owner of throng hisobuilds nempoyees,pvathercatand OCC.GROUP RFS.UNITS
who does
ments work Are nor
himself edorough hisow le.If, cvvoprovided that such
Improvement•arenot Intendedoroffeco (orale.If,however,the building
ve TOTAL:
Improvement bmld within he did out
porimpove for purpserwRHuve
tl(,kivden weer ing of the p he did na exclusively
improve ting with licensed
QTY. PLUMBING PERMIT FEE FLOOD?ANE APN
Lf L as owner of the property,•m ex0K Business
ess andWg with licensed PERMITISSUANCE
The Co onto mrmrenthe project(Sec appy to inem and Professions Code:
The Contractor's improves
License Law does not apply to an owner d property who
c lids or improve thereon,and who contracts for such ptojetts with a ALTER-DRAINk VENT-WATER(EA)
e tt(adorIs)
exemptlicensed
under pursuanttothe Contractor's License Law. FEF.SUMMARY
L.JI am exempt under Sec. B&P C for this reason BACKFLOW PROTECT.DEVICE
GRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
• Owner Date RECEIPT If
WORK MAN COMPENSATION DECLARATION
111PER.TRAP SCI'IOOL TAX Y N
111 hereby affirm that I have a certitkate of consent to set!-Insure,ore RECEIPT M
certificate of Workers'Compensation I.rarce ora certified copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PAFIE Y_ N
3800,lab CJ RK —
Po11ry N vyc y�ovaa F�
N
GAS EA.SYSTEM-OVER 4(EA)
Com nv IG 3TC-� BUILDIDINGG N
DI VISION Fr.IiS
Certified copy Is
Certified copy Is filed withh the
herebytd. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
he city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA."FT. Date RCCCI tJl
(This section need not be completed if the permit is for one hundred dollars
($1 W)or tem.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
I artily that in the performance of the work for which this permit Is Issued,
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING PAID
Workers Compensation Iowa of California. Date
C• Z Applicant NEW RESIDENTIAL PCMB. SQFT. Date Remi tit
Z O NOTICETO APPLICANT.If,after making this Certlflate of Exemption,you
U
become subject to the Worker•'Compersation provisions of the Labor TOTAL:
CC H Code,you most forthwith comply with such provisions or this permit shill be BUILDING FEE
W j deemed revoked.
W — CONSTRUCTION s LENDING AGENCY - SEISMIC FEE
F
D z Thereby orkf for
which this
aermUv tion lendingIssued(Sec. agency 7,Civ. .) perform T ELECTRIC FEE
0 Z LenAc the work(oro whkhthIs permit is Issued(Sec.309x,Civ.C.) PLUMBING FEE
LL O 1<ndelr Naar
F ixnder'e Address QTY. MECHANICAL PERMIT FEE
OW 1certifythat l have read this application and statethatme above information MECHANICAL FGE
1 is correct.I agree to comply with all city and county ordinances and state lam PERMIT ISSUANCE FEES PAID:
>. 0. to building construction,and hereby authorise representatives of this
F N city to enter upon the above�mentiunet property for inspection purposes. ALTER OR ADD TO MECH.
Z (We)agree to save,Indemnify an d keep harmless the City of Cupertino Data RimeipHl
O saga tllabilltks, eandsxpenseawhichmaylnanywayaccmr AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agai t I cAyin nsequ the tingd Is it.
AIR IiANDWNG IINT'f(OVER 10,000CFM) CONSTRUCTION TAX
Ig t-re pplian/ ntraetor Date EXHAUSTIIOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willthe applicant or fu eebullding occupant store or handle havrdou• HEATING UMT(TO 100,000 BILI) DateReCel lie
material as defined by the Cupertino Municipal Code,Chapter 9.IZ,and the
I faith and Safety Code Section 75532(a)? HEATING UNIT(OVFR I WOOD BTU TOTA
❑Ye M No
Will the applicant or future building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hasurdous air mnmmir arm as depned by the Bay Area Nr
. Quality Management District? BOILEROOMP OFB'OR 100,"RTU
4Yes sa❑❑No ��qq
havereadthehamousmuteriabrequirements under Chapter 6.95of BOILER-COMP(OVER103,000BTU) P P
the California Health&S fety Code,Smloe Z5505,75533and2SSM.I
understand that if the building does not comently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT.
rnpomilelity to notify the occupant of the requirements which most be met �q�y 2l /,Sas
prior to lssuanm d a Certificate of Oreop Ixy. 1 3992
CIl Y
(M , Ur.,�•. JV�
Owner or authorlsd agent Date ISSUEDBY: C.�'�"_TYl
TOTAL:
OFFICE COPY