23495 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bullets Project Identlrkadun PERMIT NO.
B°"d`°g"dits23495
eyre— I I AL DA IL
CITY OF CUPERTINO-BUILDING DIVISION rf
C tmctoesNamc: i1�[['Ja: APPLICATION / PERMIT �'`e �/
�iyG 7 F/s 3BUfLDINGELFGTRICALPLUMBING-MECHANICAL CA SCARY CONTROL p
.I A t / Rinser. Llc.Na
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE QI
LICENSED CONTRACTOR'S DECLARATION L�
IMhSb on7OOOffirm utlemllcensed i=3o(heunder BURIravldowof Chapter9(le,and o- APPLIANCESRESIDENTUL jO DrSCREMON
It ..t t fon700Wof Dl effect (the Bustwuand IsroleWondCode,and my
Rcense lain full! and effect PANELS ♦T Qc
Llcenap Lk.N
Date Contractor
ARCHITECTS DECLARATION 201-t ODO AMPS
p�uaZ Iunden/and my platy shall be used upubue records OVERIODOAMPS
Fi Licensed Profeniawl SIGNS ELECTRICAL p
�6 OWNER-BUILDER DECLARATION
7p, /a Ihereby af(Irm that lam exempt fromthe Cont ractor'd Lkende Law far the SPECULCIRCN7/MIST Il II
oo Q following reason.(5ectlon 7031S,Buefnmand Profusions Code:Anycity,or a♦ �j� q
TEMP. OR I'°LE'NST.
F4�N rountywhich req.re .perrnitWmwtrucyalter,impmve,dennlbh,orrcpair DATE xG� ♦C aj
anystructum pricrto its bauance,aborequlresthe applicant forsuch permitto
file a signed statement that he is licensed punuent to the provisions of the POWER DEVICES
SOI- Contractor'sLicense Law(Chapter 9(rommencing with Section 70M of Divi- SWIMMING POOL ELECTRIC
J7 skm3 ofthe Buslnesand Profusions Code)arthat he is exumpttherc(romand VALUATION
�.' the bub for the alleged exemption. Any violation of Section 70315 by any O
« OUILETSSWITCHES17I)('1'URES
fivepermit subjects the applicant to a civil penalty of not nnrethan
five hundred dollen(5500).
I,as owner of the property, NEW RESIDENTIAL ELECTR__SQ}7. STORIES TYPE CONSTRUCTION
7�n ❑ p perty,or my employee,with wagon r[herr dole -_
compensation,wideo the ness and rlrand lons,Cde: his nmbranded or..Loffered for
�O sk(Sec.7014,Business and Profwlons Code:The Contradoh License law
$ dos not apply to an owner of property who builds or improves therms,andMC.—GROUP RFS.UNITS
whodossuch work hlmslf orlhraugh his own employees,provided thatsuch
improvementsare not Intended oroffered fwwk.IL however thebuilding or T
improvement bsold withinamrarofmmpletbn,theowner- Hderwiil have
try9. rden ofperving that Its did not build arimprove for purpose ofuk.). QTY. PLUMBING PERMIT FEE FLooDzDNE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMITISSUANCE
contractorsto construct the project(Sec.7044,Businessand Profeslons Code. C
The Contractor's License,Law dm not apply to an owner of property who ALTER-DRAIN&VENT-WATER(FA)
Wilda or Improves thereon,and who comma for such plume with a FEE SUMMARY
cgptrcter(s)licensed
pursuant to the Contractor's License Law. BACK FTAWPROTFiCT.DEVICE
LII am exempt under Sea B k P C for this reseon
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y OUTSIDEN
Dm RECEIPT N
WORKMAN COMPENSATION DECLARATION ITXTURFS PER TRAP SCI{OOL TAX Y N
I-KII hereby affirm that I have a certificate of consent to self-Inrc
w ,ora RECE[in N
cerificam.Workers'Compewatian Insurance oracertified copy thereof aee. GAS FA.SYSI'EM•11NC.d OUTLETS /'w PARK FEE Y N
3800,Lab C.)
Paltry p 12 a 3Pay � RETEST p
GAS-EA,SYSTEM-OVER Co,_Cert / BUILDING DIVISIONITES
ILF]JBi Certified copy k filed
GREAS12ANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certifletl copy b filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE y-EWER-SANITARY-SPORM F.A.200FT Date Recei tk
(fhb section need sat be completed[(the permit is for one hundred dollen
(S100)orles.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
Icertify that in the performance ofthework forwhIch this penult is issued, -1 —
I shall nM employ any person In any manner w as to become subject to the WATER SYSTEM/TREATING Workers Compensation Laws of California.Date PAID
O Z Applicant
Z O NOTICE TO APPLICANT:ILafter nu king this CertRrateof Esc=n,you NEW RESIDENTIAL PLMB. SQ.F7. Date Recei ted
Fshould become subject to the Workerd'Compensatlon provisions of the Labor TOTAL:
N Code,you must fort hwlth comply with such provisions or this permits hall be
j deemed revoked. BUILDING
aCONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a ronstmctlon lending agency for the perform- ELECTRIC FEE
7 ZanceuftheworkforwhlchthbperMtbbsued eirt.3097,0e.C.) O �'
U O Lcrtder'sName PLUMBING FEE
se—
LL
I- Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I mrllfythat l have mad this applloHanand statethatthe above lnfommtion
1 I,cormet.l agree to comply with all dtyand muntyordleanonand statelaws PERMITLSSUANCE � FEES PAID:
N relating to building construction,and hembyauthorbe representative,ofthb
I- Z cltyloenterupon the abovcnentinned property for impedton purposes. ALTER OR ADD 70 MECH. Date Recei 1N
z (We)agree to save,Indemnify an d keep harmles the City of Cu pertbo
against llabuilles,judgments,cosaand expenses which may In anywayaccrue AIR EIANDLING UNIT CrO 10,000 CFM) SUBTOTAL•
a i lsaid Chy naequ ceofthegrantingrefthl>pe
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
wtureof ppuca" 0ctor Dale EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
,91 S MATERIALS DISCLOS E
Will theapplicant orfuturebulldlegoaupanl store or handle haurdous HFATING UNIT(TO 100,000 BTU) Date Recei t«
material as defined by the Cupertino Municipal Code,Chapter 9AZ and the
Ile❑alt Ynd Safdy Code,Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
Will the applicant or❑future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which cMl haeardoue air conta inantsas defined by the Bay Area Air Cis
Quality Management District? BOILFR.C.OMP OHP OR 100,IX0 BTU) If�
Yea No
have read the Eau ow malerlab requirementsunder Chapter 6.95 of BOILER-COMP(OVIR 100,000 BTU)
2SS33 ad 25534. 1 7 ex
NEW RESIDENTIAL MECH. SQ. 4�R
.e Calilomb}Iealih k Safe1
ty Code,Stolons 25505, a992
understand that i(the buildingdoca sol currently haveatenanq that 11 is my IT 1
responsibility to not fly the occupant of the mquimmenb which must be nM
prior to leaus ace of a Certi flute of Occupancy. Cf/Y Ur (;Urerl ntY
41
Owner or authorized agent Data ISSUED BY:
TO : t
OFFICE COPY