23661 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Add rest: 23661
l �t3 1x�P.T!'rSK co
caner. amps: one: p A
j rr CITY OF CUPERTINO-BUILDING DIVISION
ntrado a LIc.No APPLICATION I PERMIT
u v BUILDINGELECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL N
A hlted/Engineer. LIc Na
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Thereby af(Irmthat lam licensed underprovisionssof Chapter9(commenc AI'I'WANCESRESIDENI7AL JOB DESCRIPTION
Ingwith Sectrio�nr7000)o(DiWslon3ofthe Buslnemand ProtmlonsCode,and my
license
cn�cis, ty ie.. 3-10`18/ PANFLq Lcct �� �e
Date Contractor '_�•7
ARCHITECT 5 DECLARATION 7014000 AMPS
p7 I understand my plans shall be used as public records. OVER 1000 AMP"' SQ.FT.FLOOR AREA 5/SQ.FT.
O
Licensed Professional SIGNSELECTRICAL
�< OWNER-BUILDER DECLARATION SPECIALCItCIBT/MISC
Z
Lo., 7 1 herebyafilrenthat l am exempt from the Contractor'.License Law for the
OZ F'ggqq� RAUnving reason.(Section 70315,Businm and Profmlona Code:My city or
tri countywhlchmquimapermittommtmcyalter,impmve,dennllsh,orrepalr TFMP.ME[FR OR POLE INST.
vig3 anystmcture pdortolb Issuance,also requlrnthe applicant lorsuch permit to
]OWER DEVICES
file a signed rtatement that he Is licensed pursuant to the provisions of the
Contractors License Law(Chapter 9(commendngwfth Sedion7000)of DIVI- SWIMMING POOL ELECTRIC VALUATION
O<< tlan3ofthe Budnessand ProfemlomCode)orthathe Isewm themfromand
O Y the basis for the alleged exemption. Any violation of Section 7MI-S by any OITIT.EISSWITCHFSFIXI'URF5
E5 appVnnt into perrNt subjelstheappllcanitoadWi penalty ofnot norelhan
Ove hundred dollars MW. NEW RESIDENTIAL ELECTR
I,as owner of the property, SQ.FT. STORIES TYPECONSTRUCTION
7 p party,or my employee with wage as there sole
com(Sec.7 44,Business and
Profand the swdureheC Intended orcensoffered Law
O sale(Sec.apply
Bushes and Profmloa Code:The Contractors IArerae law
whocidoes nottapch torn imserorthreurtywhonemsoyees,oves t provided that such
OCC.GROUP RES UNITS
impmve suchw nr intmdethroffc Mis ow le.11,yees,providedthatsuch
Improvenrnb are not Intended oro!(ercd forule.I(,howeveq thebuilding o TOTAL:
improvement bsold whhin one yearofcompldioq the owner-bufiderwill have
t rden of proving that hedid nmbuildorbnprove forpurposeo!sale.). Q PLUMBING PERMIT FEB
"L as owner of the property,am exclusively contracting with licensed FLOOD LONE APN
contractors to construct the pm*d(Sec.7014 Business and Professions Code: PERMIT ISSUANCE
The Contractor's License law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon,and who contracts for such projects with a FEE SUMMARY
mntpmr(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
IJ I am exempt under Sec. B&P C for this reason
OUTS I DE FEES
DRAINS FLOORROOF,AREA,COND. SANITARY Y N_
• Owner Date RECTIIT Y
WORK MAN COMPENSATION DECLARATION FTK'NRFS PER TRAP SCHOOL TAX Y N
❑I hereby affirm that 1 have a mrtiOcate of consent to sett-ensure or a RECEBT M
certificate ofWorkers'Compeaationlesurance or a certified copy thereof(See. CAS EA.SYSTET
EM-11NCA OUTLS �. PARK FEE Y N
3800,Lab C.)
— RCCEI p
Policy N a
C� GAS EA.SYSTEM-OVER 4 U1A) BUILDING DIVISION FEES
nm ny
CertBled copy b hereby fumbhed. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
�CcrU led copy Is filed with the city Inspection division.
CERTIFICATE OF IXEMPION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.700F[. Date Recci t#
(Thissedlon need not be completed lithe permit Isforone hundred dollar
ENERGY FEE Y_ N_
(8100)
I certdifyifythat In the performance of the work(orwhlch this penult It bsvN, WATER HEATER W/VENT/ELECTR
I shall not employ any person In any manner so a to become subject to the WATIASYSTEM/TREATING
Workers Compensation Laws of California.Date PAID
OZ Applicant NEW RESIDENTIAL PLMB. �,FT. Date Recei tN
Z O NOTICETO APPLICANT:U,after making this Cediicate of Exemption,you
should become subject to the Workers'Compersation provIslou of the Labor TOTAL:
CCy Code,you rust forthwith comply with such provalora orthis permit shall be BUILDING FEE
LU > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
Il O Ihereby affirm that there Is a construction lending agency for the perform- T T ` ELECTRIC FEE
ZanceoftheworkforwhlchthIspermltbimued(Sec.3097,Cle.C.)
VO Lender.Name PLUMBING FEE _ ^
LL � Lenders Addma QTY. MECHANICAL PERMIT FEE MECHANICALFEE
O W IceAieqK
a dthbapplicatlonand statethat theabove informatron
a sconocom y with a0 city and countyordinances and nate laws PERMIT ISSUANCE �� FEES PAID:
} W elatingcoat Rion,and hereby authorize representaltvesof fhb
cit to enter the e-mentioned forty Rion ALTERORADDTOMECH.
E- Z y1311" he p"`pO9P9 Date Receipts!
(Wcove, de and ha em the City of Cupertino
V againsy rand Mich may In anyway accrue AIR HANDLING IIMT(I'010,000 CFM) SUBTOTAL-
igaiacon...r.ft42- Britoil ofthIspermB' CONSTRUCTIONTAX
AIR HANDLING UNIT(OVER 10,000CM)
eo/Appllcan/Contractor Date IXIiAl15T HOOD(W/DI1CT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appllrant orluture building occupant store or handle hazardous HEATING UNIT(TO 100,000 BM Date Recei tk
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the -
I Tealth and Safety Code Section 25537(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
M Yet M No
Willtheappllcant or future building occupant use equipment ordevices VENTILATION FAN(5INGLE RRSID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
• Quality Management District? BOILER-COMPOHPOR 100,000BTIA PAID
Yes No
have read the hazar ous materials requirements under Chapter G95 at MER-COMP(OVER100,000 BTU)
the California health&Safety Code,Sections 75505,75533 and 25534. I MAY 14
understand that if the building does not currently have a tenant,that it Is my NEWRESIDEMIALMECH. SQ.FT. 1992
responsibility to notify the occupant of the mq.im.nts which must be met s7s7
prior to issuance of a Certificate,of Occupancy. CITY
��V��l,^ufr cer��unv
Owner or authodod agent Date ISSUED BY: �+ �-/"� • 1
OFFICE COPY