23612 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prom Identification PFRb11T NO.
Building Address: O S 2 3 612
Wner9 d1M� .p Okn,e,: '
a,71�ap�QL� CITY OF CUPERTINO-BUILDING DIVISION
Gantracit 'BN me: Lic.No: APPLICATION /PERMIT
BUILDING-ELECTRICA4PLUMBING-MECHANICAL CATEGORY CONTROL p
Architect/Engineer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERNETTSSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby
actil rm0) lIvIdvlicensed under provisions;P (Chapter da,.nenc- APPLIANCES-RESIDENTIAL _7p DB F. SCRR•I'10
IngwithSMfan7000)o(DlWslon3.fthe Buslnesand ProleslonaCode,and 1 �
license b in full force and effect. PANELS
License Ctan Lic.Is
Date Contractor UP TO 2QQAMpS
ARCHITECTS DECLARATION 201-I000AMPS
�X I understand my plans shall W used s co
public records. OVER VXG AMPS SQ.FT.FLOOR AREA 4/SQ.FT.
CLicensed Professional
O SIGNS ELECTRICAL
Q w OWNER."WILDER DECLARATION
�na Et SPECIAL CIRCUIT/M6C
F'y/,6 I herebyalBrmtMt l am exempt from the Comract.rs Licens Law for the
o9F following reason.(Secllon 7mlS,Business and Profession.Code:Any city or TEMP,METER OR POLE INST.
P49.� county which rcqutmsa permit toconslmct,alter,improve,demolish,orrepair
4 �,t3Q nystructure pdorto its Issuance,also requires the applicant forsuch permit to POWER DEVICES
6 r�E V file a signed statement that he Is licensed Pursuant to the preventive of the
Contractors License CLaw(Chdssr9(commencin ith SeRion 7000)of Divi. VALUA Os sion 3ofthe Business and Profesns
sl. Cod6 m
e)orthat heexempt therefroand SWIMMING IDOL ELECTRIC n u�
the basis for the alleged exemption. Any violation of Section 7031.5 by any OU.O ETSSWI.CHE$NXTURES
<�
applicant for a Ferried s.b)ectsthe applicant to a civil penalty of out rrore than
w l dml dollars MIKE. NEW RESIDENTIAL ELECTR SQFL STORIES TYPE CONSTRUCTION
7< s owner of ted property,or my employees with wages as their sole
pensztlon,willdotheworkandthestm=m6w intendedor offered for
$ O le(Sec.704q Business and Profesimns Cade:TheComract.r.Lt..Law
does notapply to an owner aproperty who builds orimproves thereon,and OCC.GROUP RFS.UNITS
ca who does such work himself orthrough his own employees,providecithatsuch
Improvements are not Intended oroffered for sale.If,however,lhebuilding or TOTAL:
Improvement Issold within oneyearofcompletton,the owner-builderwlll have
to117unden of proving that he did not wild or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE
L_J L as owner of the property,am exclusively contracting with licensed FLOOD ZONE APN
• I'FRNfIT ISSUANCE
cemmetors to ca,retamt the project(Sec.70K Business a red Professions Code:
The Contractor's License law does act apply to an owner of property who ALTER-DRAIN 4 VENT-WATER(EA)
Wilds or improve thereon, and who contracts for such ptnjeca with a FEE SUMMARY
o�.t at rea k(s)hcensed pursuant to the Contractor:License Law. BACK FLOW PROTECT.DEVTCE
1ff,I am exempt under SB P C for this reason
DRAINS.FLOOR ROOF,AREA,CONT. SANITARY Y N_
. Owner Date RECEII'I p
WORKMAN COMPENSATION DECLARATION
❑1 hereby'afflrm that I have a certificate of consent to self-insure, PER TRAP SCHOOL TAX Y N
l(-Inre,ora RECEIPT 0
certificate of Worken'Comperaatfon Insurance ora certified copy lhersaffSec. GAS b CJ EA.SYSTEM-11NCA OUTLETS PARK FEF. Y N
3800,laRECEIPT p
On tl GAS EA.SY5TEM-OVER4 MA)
C
om raBUILDING DI VISION FG[S
[]CenyiRed copy a;hereby famished. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
MCertifled copy 6 filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Thissectionneed not ed completed if the permit Is forom hundred dollars SEWER-SANITARY-STORM EA.200FT. Dale Recei 1#
(9100)orlessJ I�V / ENERCYFEE Y_ N_
I certifythat lathe performanceof the work forwhich this permit Is issued,
I atoll not employ any person bra any manner so as to become subject to the
Workers Compensation laws of California. Date SYSPEM/TREATINK; e .r IT PAID
OZ Applicant E9 DENT AUI ' Date Recei t#
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
sheuld become subject to the Workers'Compensation provisions of the Labor _ TOTAL:
CCN Code,you mus:forthwith comply with such provlsions.rth6 permit shall be - BUILDIN
G FEE
W > deemed revoked.
a O CONSTRUCTION LENDING AGENCY SEISMIC FEE ( ^
Ihercbya(Rron that there b a construction lending agency for the perform TOTAL: ELECTRIC FEE
7 Z anof the work for which this permit 6 bsued(Sec.3097,CIV.G.)
O O Lander.Name PLUMBING FEE
LL F Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICALFEE
OW Icentifythat l havereadthisapplicitionand siatethatthe above Information
1 Iscorrect]agree to comply with all city and countyordinanms and state laws PFRVIITISSUANCE FEES PAID:
>_ W relating to wilding construction,and hembyauthotlureprexntatbvesofthIs
Fcitytoenteruponthcwve.mentlomd propertyfor Wpection purposes. ALTERORADDTOMECH.
Z (We)agree to s ,indemnify and keep harmless the City of Cupertino Date Receipt#
V againstbabiltie gment.,cnw.ande.pen.e.whkhma in anywayaccrue AIR HANDLING UNIT ITO 10,000 CFM) SUBTOTAL'
ago red'.1d C c . ce the granting of lhi t.
0. AIRHANOUNG UNIT(OVER 10,a)QCM) CONSTRUCTION TAX
Si mmn Applcant/ n actor - D.Itp/ �. / IXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE 6/1/ A/
Will the applicant or luture building om pant store.,handle Mous HEATING UNIT(TO 100,OD0 RM Date Recef t#
material as defined by the Cupertino Municipal Code,Chapter 9.12, rad the —
Hx.I Yard Safely Code,Sectioon25532W? HEATING UNIT(OVER(00,000 BTU) TOTA
Wit)the applicant or❑future building occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as dented by the Bay Area Air
lity Marugement District? BOILER-COMP OLIPOR 100,0(0 BTU)
Ys ❑No
a have reaPP
p
d the hazardous matefla6 requirements under Chapter 8.95 of BDILER-COMP I OO,OW BN) �1 B
the California I lealth A Safety Code,Sections 255D5,25533 and 25534. 1
understand that if the building does not currently have a tenant,that itis my NEWRESIDENTIALMECII. SQ.FT
responsibility to notify the occupant of the requirements which must be mat II 11/!A� ' 1 199
prior to issuance of a Certificate of O pa ncy. o /v7 as�2
Ownaroraitlavimdagent Date ISSUED BY.
TOTAL:
OFFICE COPY