23961 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PERMITNO.
Building as Addreeo 23961
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CITY OF CUPERTINO-BUILDING DIVISION ^
c tradnra Nam: 11Gope** APPLICATION / PERMIT 't%, 2
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Architect/Engineer: Lie Nce
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: LICENSED CONTRACTOR'S DECLARATION PERMIT
ISSUANCE
Ihereby nl am licensed under provisionsofCh9(comment, APPLIANCESRESIDENTIAL
ing ,,,�-e_�_❑,.�(;�5 ❑N
h Section 7(X]O)of Division Business and Pro(essionsCode,and my
[1...le.n full I. daffect. / � PANELS
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Date ontnctor pi-1000 AMPS 1�1'VI}LLL"�Cr l:•EILiU(y
ARCHITECI'B DECLARAT OVFRIOOOAMPS SQ.FT.FLOORAREA $/SQ.FT.
Oot 70. I understand my plan shall be used v public records. r
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Licensed Professional J Y V SIGNS ELECTRICAL r 9
N
�< ,OWNER-BUILDER DECLARATION SPECULCIRCUT/MLSC
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erebyafnrthatlaexemptfromthe Contractor'sLknaeLawforthe IY'r••[l
O ".F' following reason.(SMfon 70315,Business and Professions Code:Any city or
TEMP.MMERORPOLE IN . G
countywhkepriortolhis aZ tomvrequinitheapReant for
such,orrepalr
any atvdumpdor toils lhaut mc,also sed pursuant t the
prersochpermite POWER DEVICES
K 0.S file a signed statement that M b licensed pursuant to the provisions of the
OLL Contractor's License law(Chapter9(mmnrndng with Sedion70000f Divi- VALUATION
3 G swEaThnnc lA7QL o.Ecrwc lr
S O S Old ix, t to the Alaand Profemion. Any lWidli he f Secmpttheref Omand P I n
5 the tasb for the alleged exemption. Any violation of Section no
mora
any OUILETSSWITCHESHXT[rRES
appBcant fora permit subjects the applicant to a dull penalty of not morethan
c O five hundred dollars WOO).$ NEW RESIDENTIAL ELFGTR SQ.Fr. STOW rs TYPECONSTRUCTION
�1 I,as owner of the property,or my employees with wage as thele sole
d for
7a compensation,wuand thes doro5D sak(Sec.]01Business and Pretensions Code:The Contractors License,Law
$ does not apply to an owner of property who build.or improve the. ,sad
'$^ who doessuch workhimulforthrwgh hisownemployees,provided that such OCC.GROtII' RES.UNITS
improvements are not intended proffered for sale.If,however,the building our TOTAL:
Improvement is sold within oneyearofcompldion,the owner-builderwill have
th raen of proving that he did not bund orimprove our purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD LANE APN
L as owner tr the Property, Sc exclusively Ifi costal re with its Codd PERMITISSUANCE
The Co on to mvimd the project(Seer apply
to nese and Professions Code:
The CoatrImp License law d«a not apply tct an owner of property,who ALTER-DRAIN&VENT-WATER(ENN
bursa,lir improves thereon, to
who maenads our such p(ojects with a FEE SUMMARY
c JLt{adanexempt d pendant under
Seto the Contractor•Lk&ae Law. BACK FLOW PROTECT.DEVICE
LII am exempt under Sec. B&P C for this reason
OUTSIDE 17EES
` DRAINS FLOOR ROOF,AREA,COMI. SANITARY Y_ N
Owner ECL RECEIPT N
WOR1011AN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y_ N_
F11 hereby affirm that I have a certitkate of consent to self-insure,ora REC=N
certificate of Workers'Compevatlon Insurance ora cetlified copy themof(5ec. GAS EA.SYSTEM-1 INCAOUILEfS PARK FEE Y_ N_
3800.Lab CJ RECEIPT N
Polity tl CAS EA.SYSTEM-OVER 6(EA)
Cam STBUILDING DIVISION FEES
9 ANed copy b hercbyth the cid. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�ICertl(ied ropy b(Ikd with the city inspection dlWslon.
''')e CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.20017. Date Recei I#
(rhis section need not be completed tithe permit b for one hundred dollars
(SIB(fiwIeu.) WpTFR I,IFn.ITx W/VENT/ELECTR ENERGY FEE Y_ N_
I cerifythat in the performance of the work forwhlch this permit is Issued,
I shall not employ any person In any manner n a hied to the WATER SYSTEM/TREATING PAID
Workers'Cmm alio Law, 11fomla.D to Yi
0 Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
Z O NOTICEPLI�.ANT:IL y er making this Certificate of Exemption,you
should become subjectmthe orkers'Compevatlou provisions ofthe Labor TOTAL:
w Code,you most forthwith comply with such provisions orthis pemut shall be BUILDINGFEE
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
M I hereby afrmothat there is a construction lending agency for the perform- ELECTRIC FEE
7 Z anceofthe work for which this permit b Issued(Sce.3097,Civ.C.) TOTAL:
U O lenders Name PLUMBING FEE
LL l— lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U Icertitythatl havereadthbappliationand slamthattheabovelnfamation
0 W bmrrect.I agreetocomplywith alldtyand muntyordlnanceeand date laws PERMIT ISSUANCE FEES PAID:
>. 6. relating to building contraction,and hereby authoilm representatives ofthis
Z city to enter upon the above-mentioned property for inspection purposes. ALTFRORADDTOMECH.
Date Receipt#
(We)agree to save,Indemnify an d keep harmles which
the City of Cupertino accrue AIR HANDLING UMT(TO 10,000 CFM)
V
against lbbllltles,Judgments,mmaand expense,which may In anyway accrue SUBTOTAL:
against said City in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER l0,000CFM1 CONSTRUCTION TAX
Slgvturc of Applicant/Contractor Data ExHAUS'r HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applies of or future building rampant store or ha nd to hazardous HEATING UNIT(TO 100,000 BTT, Date Recel t#
material as defined by the Cupertino Municipal Cade,Chapter 9.1 Z and the - —0
-
Healthand Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTI) TOTA l
❑Yes r!No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havrdous air contaminants as defined by the Tay Arca Air R0qq pq p5
Quality Management District? BOILER-COMP OHP OR 100,00 BTU) P A y
9
Yea No
[?have
read the b.9 usmaholab requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTI,
the Health&SafetyCode,Sect1ovntly have
a tenant that 1 JUL 14
understandCaliforniaaliforiathat Healithe buTdingdoes not Sedioentlyh,25533 and 25534ltbmy NEW REST DFNTIALMECH. SQ.FT
responsibility m notify the pant of the require nt.whichreambemet
print v rrc of Cc ateol pa ney. My or
alsv
WY
lir or authodud.gen Life TOTAL: ISSUED 0Y:
OFFICE COPY