23323 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identlflodon PF7LMT NO.
Building Address: 23323
8 — 2 one APPuC&M7M99TrrA17=
CITY OF CUPERTIN0.6UILDING DIVISION
c eta a`N\N me Lie.No:
APPLICATION I PERMIT
.L '� C.;10 0 A� 3—Lej BUILDINGELECTRICALML RING-MECHAMCAL CATEGORY CO
A iter/Fsglraar ic.No:
N�` v Z QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: 0 Jim 215 .
PERFITISSUANCE
LICENSED CON ARODECLARATION t�T
T hereby effvm that lam Rcrnxd underr provisions
ovLslone of Chapter9(comment. APPLIANCISRISIDENTIAL
IIl.aIcennxx i,Ilna -\ J/D/F/eCCC�RI�P�fION
Ingwith Scefon700n , ADhill Leiffc. PANELS {�-
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Date Contractor A13,R
-Z UPTO200AMPIl
ARCHITECTS DECLARATION 201.3 000 AMPS
roll O I understand my plans shall be used as public records. OVER IODO AMPS SQ.FT.HAOR AREA $/SQ.FT.
�j Licensed Professional SIGNSELECTRIC 1 �A
C OWNER-BUILDER DECLARATION N_
G�E SPECWLCIRCM MNS 1
Iherebyaffi.that l am exempt from the Contractors License Law for the _ ^�
IF� following reason.(Section 7071.5,Business and Profenlons Code:Any city or TEMC MEIFRO LE INST. �✓ N�
cauntywhlchrcquimsaper ttommtmdaiter,Impmve,demoibh,orrcpalrv. ,#,ssa[
nyatrudurepdortoits6wancgahomquimatheappUnntfor®c perantto yl4ERDEVICES
file a signed gatemen(that he la Bcensed pursuant to the proW,lov of the _a.
C1ya Contractor',License Law(Chapter9(commencing with Section 7000)of Divi- VALUA710NA�.\
F-Lr'OS slop Sof the Bogness and ProtesslorsCode)orthat he Is exempt therefromand SWPSMIN POOL assaN� /Id CJv
6 the ba,b for the alleged exemption. Any violation of Stolon 7031.5 by any t It burLETSSWITCHEsFIRRIRFS sss
lays`}V\
Applicant fora permit subjects the applicant to a civil penalty of nes morethan
Ove hundred dollars(SS00). NEW RESIDENTIAL ELECTRSQ.FT. STORIES TYPE CONSTRUCTION
.. ❑I,as owner of the property,or my employee,with wages as their sale
7¢ compensation,will d a the work and the structure is not Intended or offend for
O vto(Sm.70K B.gruAs and Professions Code:The Contractors License law
({ $ don not apply to an owner of property who Wilda or improves thereon,and OCC.GROUP RES.UNITS
E. whodoestruchworkhimselfor[hmugh hisownemployees,provided thatsuch
Improvements arc not intended oroffered forsale.If,however,thebuliding or TOT
Improvement issold withinoneyearofcomplet mtheowner-Wdderwill have
tEg]Znrden of proving that he did net Wild or improve for purpose of sale.). TY. PLUMBING PERMIT FEE FLOOD ZONE APN
Lj L As owner of the property,am exclusively contracting with licensed PERMITISSUANCE
contractors to construct the project(Sec.70K Business and Professions Code:
The Contractor.License law does nes apply to an owner of property who
ilds impcontractson, and who contrafm such p,jets with a
Wor rove ALIflLDGIN&VEM-WATER(EA)
r�
qq➢➢tt(TacurrW licensed pursuant tm the Contractor's Liceme Law. FEE SUMMARY
c 51 am exempt under Sec B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
Owner Data DRAINS FLOOR ROOF,AREA,CONTI. SANITARY RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCI{OOL TA% Y_ N_
[]I hereby af(Irm that I have a certificate of consent to self-Insure,ora RECEIPT N
certificate ofWorkers'Compensation insurance or a certified copy thereof(Sec.
38M Lab C.) GAS G.SI'SI'EM-t ING40UILE1'S PARK FEE Y N_
—
Poiicy a 1 `'_g 1 GAEA.SYSTEM-OVER 4(EA) RECEIT N
A
S BUILDING DI VI SJOIJ FEES
LJtert ned copy Is ed: PLANCHECKFEE
H�crtl0ed copy b fled with the city bupection division. CREASE/INDUSIRL WASTE INTERCEPTOR
1
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.700FT Date Rccci t#
(Thtsxctba need not W completed It the permit la forone hundred dollars
($100)or les,.) WATER HEATER W/VFM/ELF-CTR jN1:,.RGY FEE _ N_
I mrtlfy that to tha perfmang.m of the work fmwhich this pemnit is issued,
I shall am employ any person in any manner ro a to become subject to the WATER SYSTEM/TREATING
Workers Compensation laws of California.Date
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. le IZeCei t#
Z O N'OTICETO APPLICANT:If, maklogthis Certlflate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labar TOTAL:
W Code,you must fort hwith comply with such provisions or this permit shall be W deemed revoked.CONSTRUCTION LENDING AGENCY ••Ea Ihercbyaffirm that there is a construction Lending agency for the perform, JCf:EEZ ante of the work(orwhich this permit is Issaed(Sec.3097,C1v.C.) RINGFEE
(� O lender's Name ^
LL H Lenders Addre„ QTY. MECHANICAL PERMIT FEE MECHANICAL -
U (cart fly that l have read this application and gate that the above information
OW correct l agree to comply with aildly and county ordinances and gate laws PERMUISSUANCE / FEES PAID:
>, n' relating to building construction,and hereby authorize representatives ofthis
f.. Z city toenter upon the above-mentioned property for Inspection purposes. TFRORADDTOMECH. DBIC RCCCIPI#
(We)agree to save,Indemnify an d keep harmlev the City of Cupertino V aft HANDWNG IJNR(TO 10,0(10 CFM)agalmt liabilities,judgments,cogs and expenseswhlch may manywayaccrue UBTOTAL:
againsd ty In f the granting of this permit
Cj co ue `o AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTI TAX
Signa vrc of Appll/cant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTI NTAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or furore building occupant store or handle hazardous liFATINGUMT(TO100,000BTU) Date Recei t#
matei`Zal as defined by the Cupertino Municipal Code,Chapter 9.17,and the -
11ia1tE and Safety Code Section 75537(1)? HEATING UMT(OVER 100,000 BTU) TO
❑Yes M No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) 1$$UA EDATE
which cant hazanlou,an contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP DHPOR 100,IX0 BTU) Trp G Q
V11Yet 1�11 No Ir PY E
havereadthehazam�Tmus materials requirement,under Chapter 6.95 of BOILER-COMP(OVE2100,04)(HI IJ)
he California Health&Safety Code,Stolons 75505,25573 and 75534. I
understand that it the building does not currently have a tenant,that it Is my NEW RESIDENTIAL MECH. SQ.Ff MAR 17 ' '
responsibility to notify the occupant of the requirements which must be rret IJf.
prior to Issuance of a Certificate of Occupancy.
CITY ut- ur. Nt
Owner or authorized agent Date ISSUED
7O'
OFFICE COPY