23251 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Beildi;g Add.aa: 2 3 2 5 1
o /at G 4) wr/f9- D r
e aPhone. q
TOP 40%19 �Q �� h q r CITY OF CUPERTTN0.6UILDING DIVISION
ARMonaaRor Nann: Lie.No: APPLICATION /PERMIT
OW AI BUILDING-ELEGTRICALPLUMBINGMECTAMCAL CATEGORY CONTROL N
qW Architect/Engineer: Llc,No:
QTr ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PFRMITISSUANCE �� se ❑ ❑
LICENSED CONTRunder rDECLARATION L� u
hereby Sectioaffirmthat0(Bo br licensedundererprovWamofChaoesCocommenc APPLIANCESRESIDENML JOB DGSCRE'i70N
IngwRhSmlon 70W)of Divifect. the Buslnnsand Pro/esslonaCodc,and my
Lficarlimmae Is in full force and effect. PANELS GFA License Cbed Lk.# TT
Date GnnlfaROf LM TO 200 ANIPS
ARCHITECTS DECLARATION nah00AMIS
oZ ]understand my plaallW used as OVEROVER 1000 A.MI5 SQ. FT
.FT.FLOOR AREA 5/SQ. .
O
Licensed Professional SIGNS ELECTRICAL
Z. OWNER-BUILDER DECLARATION
G F SPEC AL CE CU T/M SC
t.., 7 Thereby affirm that lam exemptfromthe Contractor's License Law for the -
ZO F. following reason.!Section 7031.5,Business and Professions Code:Any city or TEMP.METER OR POLE IN5T.
countywhich requim a permit to mvtmd,alter,impmve,demolish,or repair
�E a anystrurture prior to Its onsuance,abo requlrealheappeeant for such permit to POWER DEVICES B
$� D 3 V
F K U Ole a signed statement that he b(Chapter 9(cod ening it the provisions of the _
Contractor's Licensewand( refesd9(commencing with Section herefe f Divi- _
InSWIMMING IDOL ELECTRIC
slon3ofthe Business and Professions Code)orthathebexemptthercfromand VALUATION
< the W ab for the alleged exemption. Any violation of Section 70315 by any PVT
OUTLETSSWITCF IFSFIXTURES
O
applicant far.permit aubjeRa the applicant to a civil penalty of net more than
$
Ive hundred dollars(1500). NEW RESIDENTIAL ELECTR WFS TYPE CONSTRUCTION
.. as owner of the property,or my employer with wages as there sole IMP
�Z� RC&cc.tl 44,Bindothe ess and rkand the s Code: h e t Intendedoninctoe or License
d for
Low
5�D k(Sec.70W,Business and Professions Code:The Contnctofa License Law
s$
does rum apply to an owner of property who Wilds or improved themon,and OCC.GROUP RFS.UNITS
whodoessuchwork himself orthrough his own employees,provided thatauch
improvements are not Intended mattered for sale.If,however thebuilding or T
Improv ntbsoldwithinomyearofmmpidion•theowner-Wilderwllllove
th,,kurden of proving that he did not Wild orlmpmve for purpose ofsals.). Qty. PLUMBING PERMIT FEE FLOOD ZONE APN
U I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractors License Law does net apply to an owner of property who ALTER-DRAW&VEM-WATER(EAI
Wilds or Improved thereon, and who contracts for such projects with a
ogRl�actor(e)licensed pursuant to the Convanorf License Law. FEE SUMMARY
I_f I +m exempt under Sec B &P C for this reason BACK FLOW PROTECT.DEVICE
ru ITS I DL FEES
Owner Date
DRAINS FLOOR ,GON
ROOF,AREAD. SANITARY Y N—
RECEIIT N
WORKMAN COMPENSATION DECLARATIONFD(IURES-PER TRAP SCHOOL TAX Y— N_
❑I hereby affirm that I have a cerlifiot,of consent to self-insure,or a RKI PT N
artlfinleo(Workers'CompemationlmunAmoram4ifiedmpylhemof(Sec' GAS EA.SYSTEM-I INCA OUTLETS PARK FEE Y N
3800,Lab C.) —
Pall Y RECEB'I N
Com any SAS EA'SYSIFTI-0VER4(FA) BUILDING D I VIS ION FE ES
Camfled copy is hereby furnished. GREASE/INDUSUiL WASTE INTERCEPTOR PLANC}{ECK FEE
❑
Certified copy b filed with the city Inspection division.
CERTIFICATE OF IXEMPFION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Da1C Receipt#
(This section need net be completed lithe permit b for one hundred dollar
(1100)orless.) WATERHEATERW/VENT./ELEGTR ENERGYFEE Y— N—
I certify that In the penormaneeuf the work forwhich this permit is bsuN,
1 shall not employ any person In any manner so as to become subject to the WATIX SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID
O Z Applicant NEW RFS DEN7IAL PLMB SQ.FT. Dale Recei I#
Z O NOTICE TO APPLICANT:If,after making thin Certilicateof Exemption,you
Hshould become subject to the Workers Compensation provisions of the Labor TOTAL:
CC IA Code,you mat forthwith comply with such provisions or this permit shall be BUILDING FE
W j deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL I hereby affirm that there bamnstruction leadingagency forthe perform TOTAL: ELECTRIC FEE
7 Z ante oftheworkforwhich this permit Is lesued(Sec.3097,Civ.C.)
02 1<ndee•sName PLUMBING FEE
Lender's Address QTY MECHANICAL PERMIT FEE
MECHANICAL FEE
O w m
ImdlfythatIhavemadthbapplicatimand restated theaboveInformation
a Iscorred.I agree to comply with all cityand com"eclnans and state laws PERMIT ISSUANCE FEES PAID:
relating to building construction,and hereby authorim representatives of this
(— N city to enter upon the above-mentioned Property for Wpectim Purposes. ALTER OR ADD TO MECH.
2 (We)agree to save,indemnify an d keep harMest the City of Cupertino Date RCCcipt#
V
against liabilities,judgments,cosnand expenses which may In anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City In consequence of t�of this permit.
A MR HANDLING UNIT(OVER Io,roocr•M) CONSTRUCTION TAX
Sig reo Appl rant/Con Date EXHAUST HOOD(W/DIKT) CONSTRUCTION TAX PAID:
HALk US MATERIALS DISC URE
Will thea lion or lurcbuildin occu ant store or handle havrdoua HEATING UNIT(TO 100,000 BTU)
PP B P Dale Receiptl
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the - /tf---
HealthandSafety Cade Section 25532(a)7 - HEATING UNIT(OVER IW,WO BTU) TOTAL: E�
❑Yes [j No
Will lhcapplirant or future building occupantoseequipment or devices VENTILATION JAN(SINGLE RESID) ISSUANCE DATE
which emit havardous air mntaMrunO as defined by the Bay Area Air
•
Quality Ma rugement District? BOILER-COMP PHP OR 100,0(0 BTU)
4Yea ❑No R� p
havemad the harardousmaterials requirements under Cha pwr&95 of BORER-COMP(OVER 100,000 BTU) Ir A Q D
the California Health&Safety Code,Sections 25505,25533 and 25534. I
understand that if the building docs not currently have a tenant,that It is my NEWRE5IDEbMALMECH. SQ.FI FEB (�
rapovibility to notify the occupant of the requirements which must W mat • � 1992
prior to issuance ed a Certificate of Occupancy. /s
Owner or authonecd agent Date TOTAL: ISSUEDB V I U L_ F -'IF'/
OFFICE COPY