23299 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification IPERMIT NO.
Butlding AadreX. 23299
/�e,cT�{S�e9� 52 -
net' one: A A A
at CITY OF CUPERTINO-BUILDING DIVISION
Conreaao•.yamr ue.No: APPLICATION /PERMIT �
3a �� BUILDING-ELF-CMCALML BING-MECHAMCAL CATEGORY CONTROL X
ArchitectEngineer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG EL�I PLUMB MLL11
Address PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION Y
T hereby affirm
on700that lamlkensedunder
usinesprovisdoes
and Pmmionsr9(emmenc- APPMANCESRESIDENTfAL )OB DESCRB'1lON
ingwith$In NU 7000)x(Dlvfect. (the Businnsand Pro/esslonsCode,and my
11 Is In s -Z)D Effect PANES
L seChss Z.D Lk.X
ate Contractor
ARCHITECPS DEC RATION 201-1000AMIS
9Z I understand my phm shagbe used as public records. OVERIODOAMPS SQ.Fr.FLOOR AREA 5/SQ.Fr.
O
dLicensed Pmfevlonal SIGNS ELECTRICAL
Q'Lln'I OWNER-BUILDER DECLARATION SI'p-CIALCR2CUIT/MLSC
I hereby affirm that l am exempt from the Contractors License Law for the
70-O y sp following reason.(Section 703 15,Business and Pmfevbns Code:Any city or TEMP.METER OR POLE INST.
ZFtil countywhkhmquknapemdttomntmo,alter,lmpmvgdemdtsh,ormpalr
�'��¢ anPOWER DEVICES
ystructure pdorto IIs Issuance,also mquiresthe applicant for such permit to
O file a signed statement that he Is licensed pursuant to the provisions of the
Contractor's License Law(Chapter 9(commencing with Section M(11)of Divi- SWIMM]NGIWLELECHRIC VALUATION
ston3oftheBusln,vand PrefessbmCode)orthat he is exempt therefromand
6 the basis for the alleged exemption. Any ,violatlan of Section 7011.5 by any OUTLETSSWITCHESFIXTURES
applicant for a permit subjects the applicant to a civil penalty of not nnrc than
five hundred dollars($W. NEW RESIDENTIAL ELECTRFT.
7
I,as owner of the property, —ems' STORIES TYPE CONSTRUCTION p perty,or my employees with wage as there sole
compensatlon,will dothe work and the structure h not intended or offend for
' Osale(Sec.7M4,Business and Professions Code:The Contractors Liceme Law
�SS does not apply to an owner of property,who Wilds or improves thereonand 000.GROU1' RES.UNITS
who doessuch work himself orthrough his own employees,provided that such
Improvements are not intended or offered for sale.If,however,the Wilding or TOTAL:
Improvement lssold within one yea rofcompietion,the owner-builderwill have
tFiLkurden of proving that he did not Wild or Improve for purpose of sale.). QTy, PLUMBING PERMIT FEE FLOOD ZONE APN
L_j L as owner of the property,am exclusively=trading with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7094,Business and Professlons Code:
The Contractor's License law does not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such projects with a ALTER-DRAIN&VENT-WATER(EA)
c actors)licensed pursuant to the Contractor's License Law. BACKFLOW PROTECT.DEVICE FEE SUMMARY
(� LJ I am exempt under Sec. B& P C for this reason 'FEES
Data DRAINS FLOOR ROOF,AREA,COND. SANITARY RECEIPT X
��. WORKMAN COMPENSATION DECLARATION I7XTURES PER TRAP
SCHOOLTAX Y N
UI hereby affirm that I have a certificate of consent to self-insure,or a gp�EB.T p
,reni0cxeo(Workeri Comperwtlonlnunnnora certified copythereed5ec. GAS EA.SYSPEM4 INCA OUTLETS PARK FEE Y N
�— 3900,Tab C. RECEIPT X
1' IayM�—�',nsl _ GA&FA.gYSI'FM-0VER4(EA) BUI LDWG DI VI SION FEES
,dified m Is hereby fumbhed. CREASE/INDUSPRL WASTE INTERCEPTOR PLANCHL•CK FEE
❑ ertifted copy a filed with the city Inspection division.
CERTIFICATE OF UMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE BEWER-SANITARY-STORM EA.200FT. Date Recei tit
(rNs section need not be completed if the permit h for one hundred dollars
(SIM)orlcss.) WATER HEATER W/VENT/ELECTS ENERGYFEE Y_ N_
I artily that U the po fornunce of the work for which this permit is issued,
1 shall not en,ploy any person In any manner an as to berome subject to the WATER SYSITM/TREATING
Workers'Compensation Laws of Callfomh.Date PAID
0 Z Applicant NEW RESIDENTIAL PLM B. SQkT. Date Recel t#
NOTICE TO APPLICANT IL after nuking this Certificate of Exemption,you
Z O
kers
should become subject to the Wor ''Compentation provisions of the Labor TOTAL:
I-
0
ro
� > Code,you=atforthwRh comply with such pvIslorn or this permit shall be BUILDING FEE
W deemed revoked. SEISMIC FEE
IL O CONSTRUCTION LENDING AGENCY
Iherebyaffirmthat there is a construction lending agency for the perform TOTAL: ELECTRIC FEE
3 Z ares of the work for which this permit Is Issued(Sec.3097,Civ.C.) PLUMBING PEE
00 Lenders Nam
LL H Londer's Address QTy.I MECHANICAL PERMIT FEE MECHANICAL FEE —2.3 jeasa
I ertilythatlhav dthhappbation and Aatcthattheam
bove information
on W
IL 1'. ct.Ia ocem ly with all city and countyorAlnances and state laws I PERMIT ISSUANCE FEES PAID:
>_ relatingt uildingen trudmit,and he authorize representatives ofthi,
N ALTER OR ADD TO MECH.
City to ent r uponth bova mentloned erty for inspection purposes.
? e)ogre to c,Indemhity an harmless the City of Cupertino Dale ReeCIPtN
V ag tllsbil I dgmet.,costsan ex non which may Inanywayamue AIR HANDLING UNIT(O 10,ODO CFM) SUBTOTAL:
a lost
aald In con. en f t e gr ting of this permit.
m AIRHANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Sig.wm fAppllant/Contactor Date EXHAUSTHOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UMT(TO 100,000 BTU) Date Recei tN
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
I leahh and Safety Code Section 2SS32(a)i HEATING UNIT(OVER 10,000 BTU) TOTAL
nYn riNo '
Will the applicant or future building occupantuse equipment or devices VENTILATION FAN REBID) ISSUANCe FyDATE
which emit hazardous air contaminants as defined by the Bay Area Air ? A E
Quality Ma rugement District? BOILER.COMP OHP OR 10Q00D BTU)
is ❑❑No (1
44I Yv read the haurdousmatedalsrequircmentsundnChapter G95of BOIf.ERCOMP(OVER 100,000BTU)
the Callfomla HnIth&Safety Cud,Se iom2550.5,2 D3.nd25534. I
understand that if the building does not currently have a tenant,that It Is my NEW RESIDENTIAL MECH. SQ.FT
rriorto issuance
ofa Cehe ocdoof of panty.lremenb whkh mustbemet J1 Ur
Prior to Issuance old Certi(iateofOmpancy. r1j{
Owner or authorized agent Data ISSUED BY
TOTAL:
OFFICE COPY