23044 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildingProject Identification PERMITNO,
Building Address: OQ .� 23044
C
ncr• ossa: one: p
CITY OF CUPERTINO-BUILDING DIVISION
Conlr ttw's ossa: - Lic. o: APPLICATION I PERMIT
BUILDINGS.ECTRICAL-PLUMBINGMECHAMCAL CAIFf-0RY CONTROL N
QjArchl / glnnr. Llc Na:
Q ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addresc PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirmthal l am licensed under provisions of Chapter 9(mmmmc APPWANCESRESIDENIAL - JOB DFSCRB''DON
Ingwlth Seni.n7000)of Dlvhdon3 ofthe Busha ssand ProfessionsGod[,and m
license ie in fu o d affect. PANELS
Lleen�Llc.N
Dale Contractoracmr 7011000 AMPS
ARCHITECT'S DECLARATION
Ore zp my plan sheE be used v public records.Iunderstand OVERIODOAMPS SQ.Fr.FLOOR AREA $/SQ.FT.
Licensed Professional SIGNS ELECTRICAL A L E D IN
OWNER-BUILDER DECLARATION P E R
lea SPECULCIRCOR POLE
l
zF. ,7a Ihereby affirm that l am exempt from the Contradoes License Law for the
QQfollowingreason.(Section 70315,Businessami PImprovv Code:Anydty or
� I'ty countywhlrA requlreaa permitbmvwct,alter,Improve,dennlbh,orrepalr TEM['.MEITR OR POLE[
any-tmMmpriortoitsl ancealsomquimtheappli"ntforsuchper to
AOWER DEVICES
fib a signed statement that he la licensed pursuant to the provbiov of the DATE
O u, Contractor's License Law(Chapter 9(commencing with Sedion 7000)of DWI-
SOS slon3.lthe3utln and Profmss mCode)orthathebexemptthemfmmand SWE.TbBNG ELECTRIC VALUATION
< the bnab for the alleged exemption. Any vlolallon of SectW.70315 by any
applicant fora permit subjects the applicant to a civil penalty of not morelhan OUTLETS TCI IESFIXTVRES
five hundred dollars($500). NEW R- ENr1AL ELECTR
�n
E]1,as owner of the property,or my employees with wages as their sole _SQ 1-7. STORIES TYPE CONSTRUCTION
m.Penaati..,.Hl do/hew.rk,and thesmmhe isnot Intended or offered for
O sale(Sec.7044L Business and Professions Code:The Commences LI¢ve law
$ does not apply to an owner of property who builds or impravesthm=N and OCC.GROUP RES.UNITS
whodon such work hlmselforthrough his own employee,provided that such
improvements are not Intended or offered fee sale.If,however,the building or TOTAL:
Improsencetbseld within oneyearofcompldioglhe owner--der...... e
tl)9, rden of proving that he didnd build or improve for purpose of sale.). OTY PLUMBING PERMIT FEE
IJ FLOOD ZONE APN
I,as owner(r the property, Se.70K Bely mntretting with II¢nsed PERMITISSUANCE
mntratton to mvWtt the project(Sec.70K Business and ProlemWv Code:
The Cmd.does License Lw does not apply to an owner of property who ALTER-DRAIN kVENT-WATER(FA)
builds or Improve thereon,and who mrdred.fou such pk j u with• FEE SUMMARY
cgR{lactwW B¢nsed pueuant to the Contract.e.License Law. BACK FLOW PROTECT.DEVICE
I_I I am exempt under Sec B It P C for this reason
DRAINS.FLOOR,ROOF,AREA,CO SANITARY Y N
Owner Date BBC=N
WORKMAN'COMPENSATIONDECLARATION FIXTURES PER TRAP SCHOOL TAX Y N
❑I hereby affirm that 1 have a certificate of consent to self.Insure,or• RECEIPT Y
nrtlR¢te.fWorkeee'Cwnpevatl.n lnaurance wa¢nilhd copy thereof(Sec. GAS FA.SYSTEM-1 WCN ETS PARK FEE Y N
3800,lab CJ
PdkyY GAYSTEM-0V Y( A)ERECEIPTY
GEM S F.A.EA. BUILDING DIV]SION FEES
Cadifled copy is hereby furnished. GRCASE/INDU WASTE INTERCEPTOR
❑Certified copy b filed with the city inspection division.
CERTIFICATE OF E(EM PTION FROM WORK ERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER. ARY STORM EA 2(pRf
(Thlssectlon need not becompleled lithe permit isforonehundred dollarsDate Recel t#
($I00).eleea WA TERW/VENT/ELECTR ENERGYFEE Y N
Icerti(ythat Nthe performana.(the wwk(arwMch this permit lsbaed, —
I shall not employ any person In any manner so v to become sebject to the WA
Wwkcre'Compewtlon Iowa of California. Dale SYSfFM/TREATING Pplp
Z Applicant RESIDO-MALPLMR, SOF['. Date RBcei tR
Z O NOTICE TO APPLICANT:If,after nuking this Certifkale of Exemption,you
should become subject to the Workers'Compensation Provbl.v 01 the Labor TOTAL:
N Code,you=at fad hwith comply with such provblov or this permit ahallbe
j dearred revoked. —.WILDING FEE
W C CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Z Iherebyaffirm shat there is a mvtmttion lending agency for the perform- TOTAL: ELECTRIC FEE
...of the work for which this permit Is bsued(Sec 3097,Civ.C.)
I, O Lenders Name PLUMBING FEE
LL !- Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICALFEE
OW I¢rtifythatl have read this appli¢tlonand Natethat theabove lnlormalIon
1 bmrmci.!agree:.comply with all city and muntyordlnancca end katelawe PERMITISSUANCE /5 EES PAID:
>- W relating tobuilding mvlructlon,and hereby authorize representatives of this
H Z city to enter upon the abovrmendred property for impecilon purposes. ALTER OR ADDTO MECH.
(We)agree to save,lndedo fy en d keep harmless the City of Cu Perrino Date Recei t#
V aiiisiritBabI des,�dgmentk mesandexpensewhichnuylnanyway roue AIR HANDLING UNITRO l0,f100CFM) SUBTOTAL:
i said try con equeom of the gr min thio perm .
��j� AIR FUNDWNC UNIT(OVER10,000CFM) CONSTRUCTION TAX
Signature l' ppl cont '.etre 7 EXHAUST HOOD(W/DLICT) CONSTRUCTION TAX PAID:
HA7ARD0 ATERIALS DISCLOSURE
Wllltheapplicantorfmme uOdingottupant storeor handle hazardous HEATING UNIT CFO 100,000 BTU) /
malarial as defied by the Cupertino Municipal Code,Chapter 9,17,and the Date ReceI t#
Health and Safety Code Section 75537(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: •�
❑ Yes No
Will the apphantorfuture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air mnlaminants as defined by the Bay Area Air
Quality Management DlsMct7 BOILER-COMP OHP OR 100,000 BTU) p A
r]
Y. ❑n No If" Pct
ave read Healthe h
a Safety
Code,Section,
255nbunder Chapter.1 of BOILER-COMP(GVER 100,000 BTU) e �j��'�'\
the California tHealth Yr Safety Code,noctiov755haveaT3and,that 1 �I1� OV 199
understand that If the notify
the ing occupant
nwmrequir haves which:,that It homy NEW RESIDENTIAL MECH. �Ff
rmpovWBlty 10 nollfy the omvpant.f the requirements which must be met
prior to Issuance of a Certificate of Occupancy. CITY Ur wr IcHll�
Owner or authorized agent Date ISSUEDBY
TOTAL:
OFFICE COPY