23264 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Adel 23264
2-oz-noNar4-IibrocK,
,, 1 `�� 3/-- one,
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Jt�a1&Valle" y�631 CITY OF CUPERTINO-BUILDING DIVISION M^
. c. . Nan= u . APPLICATION / PERMIT
l0 BUILDING-ELECTRICAL PLUMBING-MECHANICAL CATEGORY CONTROL X
Archite</Engineer. Lie.Ner
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
BLDU
Address PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby af(Inn that lam Ocrosed under provisions of Cha)der9(mmmmc- APPEANCESRESIDENTIAL JOB DESCRIPTION
Ingwith Section700D)of Division 3 fthe Bwlncss nd Profesdons Codc,andmy
license 7 n fyB(o d dfeR�� PANELS
License, Lh
Date G011ITE 2011000 AMPS
AR ,hall DEC TION OVERID00AMPS SQ.FT.FLOOR AREA S/SQ.FT.
a0 7O I understand my pons shall be used u public records.
,t°tLl�j Licensed Professional SIGNSELECTRICAL
OWNER-BUILDER DECLARATION
LGSS Ihereb a(8rm that l am exempt from the Contractors License Law for the SIPLCWLCIiCU1T/MLS,
Vpo following moson.(SMIon 7031 S,Business a ed Professions Code:Any city or
III county which requlecta permit roconstruct,alter,Improve,demolish,orrepair TEMP.METER ORIOLE INST.
Fogaa, any structure prior to its iosaan,e,also requires the applicant for such permit to POWER DEVICES ..I \ ,1 II
�y�U file a signed statement that he Is licensed pursuant to the provisions of the ' t .,,.J IIEF
Comractor'e LicemcLaw(Chapterg(rom
mencin 7000
with Section )of Divi-
IL
�30r simiof the Business and ProfelonsCode)orthatheisexem therefemmand SWIdMNGIOOLF7EC OC /
a 5 the basis for the alleged exemption. Any violation of Section 70315 by any
OUTLETS-SWITCHES-FIXTURES U/�I
0
VAZ
applicant for a permit subjects the applicant to a civil penalty of not more than
five hundred delta.($SM. NEW RESIDENTIAL ELECTR
n1,as owner of the property,or my employees with wages as their sole SQFL STORIES TYPE CONSTRUCTION
compensation,will do the work and thestrvtture is not intended or offered for
D sale(Sec.7064,Business and Professlom Code:The Contractors License Law
tj5$ does not apply to an owner of property who Wilds or improves thereon,and OCC.GROIIP R25.UNITS
E who doessuchworkhimselforthroegh hisown employees,provided thatsuch
Improvements arc not Intended oroffered forsale.If,however,thebuliding or TOTAL:
Improvement bsold withlnoneyearofcompletion,the owner-builderwill have
t rdenof proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE MOOD TONE APN
UI,as owner of the property,am exclusively contracting with licensed fFRAfIT LSSUANCE
contractors to construct ct the project(S70K Business and Professions Code:
The Contractor's License Law does net apply to an owner of property who ALTER-DRAIN&VENT-WATER(EM
Wilds or Improves thereon,and who contracts for such p�ojeats with is
Cq➢I�ctor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B&P C for this reason
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N� ��
Omer Date RECEIPT p
WOR• ,f�IficaeOyoff[ tAN;haveOM!cIrtu�neef consent to Pythsure,oereof ec.ON FTXTIIRES PER TRAP SCHOOL TAX RECEIPT 11
38m,1ab � GAS EA.SYSI'FM-1 WC.60UTLETS PARK IEE Y_ N_
�1// RECEIPT N
Polity N CAS FA.SYSITM-0VFR d(FA) BUILDING DIVISION FEES
Cam any_ bIAH ant'
�Certifled copy Is
m s e . CREASE/INDUSIRL WASTE INTERCEPTOR PLANC14ECK FEE
I�edified copy V filed with the city Inspection division.
CERTIFICATE OF IXEM PTION FROM WORK ERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Recei tM
(Thissection need not W completed If the permit is forom hundred dollars
(s)m)mIces.) WATER HEATER W/VEM/FYECTR ENE•RGYFEE Y_ N_
I comlythat in the performance of the work for which this permit Is Issued,
I shall net employ any person In any manner w as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation laws of California. Date PAID
OZ Applicant NEWRF9DENTALPW B. SQ FT. Date Recei tf
Z O NOUCETOMMICANT:ILaftermakingthb CeAYI.teof Exemption,you
should become,subject °r
to the Wke.'Compensation provislons of the Labor TOTAL:
q2
Code,you must fort hwith comply with sort,provisions or th is permit shall be 13UILDINC FEE
W ] deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 e I herebyafOrmthat there It aromtmctl.n lending agency for the perform ELECTRIC FEE
M Z an.of the work for which this permit to Issued(Sec.3097,Civ.C.) TOTAL:
U O lenders Name PLUMBING FEE
IL Lenders Adders QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U Icertifythat I%ve readthisapplicatlonand datethattheabove Information AA
O W to d lag to comply with all dtyand rounty.nllnancesand date laws PERMIT ISSUANCE , a FEES PAID:
} IL reletlegtob Ing mm-dion,and hembyauthorize represn.tivesofthis
F Z my to enter .the above-mentioned property for Wpml.n pu ALTERORADDTOMECH.
(We)a ve,indemnify and kaep harmiess the City a Cu Ino Date Rmciptit
V
Bate)
1146i meet.,ce expenseswhic yin an way AIR HANDENG UNIT(TO 10,000 CFM) SUBTOTAL:
agnimt d n e oft egranting of perm
AIR HANDLING UMT(OVER 10,000 CIM) CONSTRUCTION TAX
signature Applicant/Contractor Datc IXHAl15T ooci(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISC IOSUR
Will the applicant or future building occupant store or handle havrdous HEATING UMT(TO 100,000 BTU) Date Recei IN
matertal as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Ilealth and Safety Code Section 25532(a)2 HEATING UNIT(OVER 100,000 BM TO A ��
Yes MNo F
VENTILATION FAN RFSID)
Will the applicant or future mild e.,de fine use equipment or devices ISSUANCE DATE
which emit hagements airrict? nes as defined by the Bay Area Ail
•
Quality Management District? BOILER-COMP(3FN OR 100,0(q BTU) /
4Yes ❑❑No
havelead the hxlJRM materials qulremnsundcrChaper6.95o( O ER-COMP(OVE100,000BM
the Glifomta Health&SafetyCode,Sectio.25505,25533 and 25534.I
understand that if the building does not currently have a tenant,that B is my NEW RESIDENTIAL MECH. SQPT AUG
ro p.mibBity to notify the occupant of the requirements which most be met t9 2 y 1aar,
poor to issuance of a Certificate of 0.pct ncy.
CII
owner or authorlud agent Date IVSD BY: .vu
TOTAL:
OFFICE COPY