23908 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project IdentificationPERMIT NO.
Building0 j, 70 N( 23908
Te 2 —760% A
CITY OF CUPERTIN46UILDING DIVISION �_ D
Coptpc3pry,N�(, G" No- 9 APPLICATION / PERMIT
Architect/Engiireeeer. Lit.No: BUILDINGELECTRICA4I'LIMBINGMECFUMCAL CATFLORY CONTROL X
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address PERMTISSUANCE ❑ 1:1 El
CONTRACTOR'S DECLARATION
I hereby Sectioaffirm that lamlken3ofthe usineprovisions
andP ffesk=sr9de,and c- APPLIANCESRESIDEMTAL JON DESCRB'TION
irenseISection force and effeon3ofthe Bualnessand Prolcaslone Code,and my
license Is Ins force and cited. PANELS
License Cha Lich
Date Gantmdar
ARCHITECTSDECLARATION 00 AMPS
�Z 1 understand my plans shall W used as public records OVEROVER 1000 AMPS SQ.FT.FLOOR AREA SISQ.F[.
CO
d(� Licensed Prol.lonal SIGNSELECTWCAL
Q w OWNER-BUILDER DECLARATION
res a Fn SPECIAL CII(CUIT/MLSC
Thereby affirm that lam exempt fromthe Contractor's License law for the
oo following reason.(Sectlun 7NIS,Business and Professions Code:Any city or
�,zl"' cauntywhichrNulresapem trommtmM, te,lmprov demolbh,orrepair T�PME7ER OR TOLE INST.
anystmc mpMrtoi SE ancgataorequirestheappBcantforsuchper tto POWER DEVICES
K U file a signed statement that he is licensed pursuant to the previsions of the
Contractor's License]aw(Chapter9(commencingwith Section 7000)of Did. SWIMMING POOL ELECTRIC VALUq,'LOSJ
O slon3ofthe Businessland ProfmlomC.de)ortbathebexem thercfmmand (rQ
Qthe bash for the alleged exemption. Any violation of Section 70FIS by any OUTLETSSWITCHES-FIX1URES L an
<� applicant fora permit subjects the applicant to a civil penalty of nal morethan a+� 2-0.
dreddolla1t$h ). NEW RESIDENTIAL ELECTR SQ.Ff. STORIES TYPE CONSTRUCTION
Z Las owner of the property,or my employees with wage as their sok
p atlan,wBldothe work and thestmcture b not intended or offered for
$ k(Fee 70$X,Bmineas and Profmlons Cade:The Contractors Untrue law
�s$ don not apply to an owner of property who Wilds or improves therms,ano. d OCC.GROUIa RFS.UNITSwhodoessuchwarkhimxlforth=ghhisownemploym providedthatsuch
Improvements are not intended proffered for sale.If,however,the building or TOTAL:
Improvement bsold withinoneyearofcomple im,theowner-builderwill have
t"eden of proving that he did me Wild or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLODDTDNE APN
LJ L as owner of the property,am exclusively contracting with licensed pRMIT ISSUANCE l•
contractors to construct the project(Sec 7M4,Business and Profmbw Code:
The Contractor's License law does not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such pPinots with a ALTER-DRAIN&VENT-
WATER(EA)
cgp[+dods)licensed pursuant to the Contractors License Law. FEE SUMMARY
1_j 1 am exempt under Sec. B At P C for this reason BACK FLOW PROTECT.DEVICEOUTSIDE FEES
DRAINSFLOOK ,AREA,CONE). SANITARY Y_ N_
Owner Date RECEIPT If
WORKMAN COMPENSATION DECLARATIONFIXTURES-PER SCIdOOL TAX Y_ N
❑1 hereby affirm that I have a certificate of consent to self-Insure,or RECEIPT N
mKificusofWorkers Compensation Insurance ora.milled copy thereof 6ec. GAS EA.SYSTEM-1 INCX PARK FEE Y_ N_
3800,lab C.) RECEIPT X
Policy# CAS EA.SYSTEM-OVER EA)
Com any BUILDING DIVISION FEES
Certified copy In hereby furnished. PLANCHECK FEE
❑Certsed copy is Bled with the city Inspection division. GREASE/WDUSIRL WA RC TOR
CERTIFICATE:OF EXEMITION FROM WORKERS' CREASE TRAP PAID
COMPENSATIONINSURANCE SEWER.SANITARY-STORM EA. Date Recei t#
(TMs section need not be completed litho permit b far oK hundred dollen
($100).'1..) WATER HFATERW/VENT/ELFJCTR ENERGY FEE Y_ N_
1 certify that In the perfornunceof the work forwhich this penult is Weed,
1 shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers Compensation Laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Reeef t#
Z O come NOTICETO APPLICANT:If,after making this Certificateof Exemptionyou
should besubject to the Workers'Compensation provisions of the Labor TOTAL'lip
CC W Code,you moat forthwith comply with such provisions or this permit shall be BUILDING FEE
deemed revoked.
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 C Iherebyaf@.that there is a corotmction lendingagency forthe perform- ELECTRIC FEE
M Z ante of the work for which this permit is Wued(Sec.3097,Civ.Q TOTAL:
O O Lender.Name PLUMBING FEE
f I.ender's Address QTY. MECHANICAL PERMIT FEE
LL U Icenifythat l have read thkapplication and statethat the above information MECHANICAL FEE
0 W boomed.I agreeto comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} C relating to Wilding oomtmction,and hereby authodo,representatives of this
F Z city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
BVe)agee t.save,indemnify a.d ke harmim me City.(Cupertino Date Receipt#
Z5 ilia
nts,00stsand pe nes whidsmayina.ywayseems AIR HANDLING UNIT(TO Ift"CFM) SUBTOTAL:
a of tingofthispemmlt.
.a/ AIRHANDUNGUNFT(OVFAIO,000CFM) CONSTRUCTION TAX
cpntraddr ate E%FIAUS'T HOOD M/DUCT) CONSTRUCTION TAX PAID:
RDOUS 'RIALS DISCLOSURE
'future buildingoaupant store or hand le havardous HEATING UNIT 100,000 B'N) ReCei t
material as defined by the Cupertino Municipal Code,Chapter 9.12,and thetit
❑ealth and Safety Code Sedim 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTA :
❑Yrs r]No
WIII the applicant or future occupantVENTILATION EAN(SINCLE RFSID)building opant use equipment or devices ISSUANCE DATE
which emit haaa rdoos air contamim rats as defined by the Bay Area Air
Qu a lity Management District? BOILER-COMP(311P OR 100,0M BTU) '
4F�
Y's F❑� a
havereadthebaza oNmaterials mquirementsunder Cha pier 6.95of BOILE .�R-COMP(OVERIM,000 BTU) 4 �®
the Califomla Health&Safety CWe.Sedions 25505,25533 and 2S53X. I
understand that if the building don nm mrrently have a tenant,that It is my NEW RESIDENTIAL MECFL SQIT Ex"//�
mg(7
pHi
omity to notify the occupant of the requirements uirees which must be net V
prior to Issuance of a Certificate of Occupancy. co? ` 0 , as/l`'r.'X7/`�/\
_ l r s7C`
Owner or authorised agent Date TOTAL: ISSUEDBY: �T/ ..�
OFFICE COPY