23780 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: 23780
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-a D Cls GIS/ I
era o p A
ry rre. Kr _ CITY OF CUPERTIN0.6UILDING DIVISION 2—
Contra Name: LiN. APPLICATION / PERMIT
G BUILDING-E.ECTRICAI.PLUMBING-MECHANICAL CATEGORY CONTROL N
Architect/Engineer. Lie.Na:
QTY ELECTRIC PERMIT PEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ ❑ El
CONTRACTOR'S DECLARATION
I herebya.n 7000infant licensed ofthe usines provisions PrfChapterode,anenc- APPEANCESRFSTDENTIAL JOB DESCRIPTION
Ing with Section 7000)of DiNnon3 o(tM1e Bml news and ProfesslonaCode,and rry
liana Is In full fora and effect. PANELS d''�
Llanx CWn Lia N _ c-G
Date Cr UP TO 2DO AM 701-1110 AMPS
ARC HTFECSDECIARATION OVERIODOAMPS SQ.FT.FLOOR AREA S/SQ.Fr.
0] I understand my plans shall
haB W be used as public recrrtls
qq{� O
E fi�j
Licensed Professional SIGNS ELECTRICAL rr__
<« E�® N
�6 OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC
�laa Ihereby affirm that lam exempt from the Contractor's License Law for the
F 9 t- following reason.(Section 71115,Business and Professions Code:Any city or j
county which requires a permit to construct,alter Improve,dernalish,mropatr TEMP.METE20R POLE INST.
¢m�maga�< any swcturc prlorb its issuance,also mquimstheappllcant for such permit to POWER DEVICES v + V
ES K a V file a signed statement that he Is Ilamed pursuant to the provL+low of the
a G Contractor's License Law(Chapter9(mmmencing with Section 700))ofavi- SWIMMING POOL ELECTRIC _ ALUA N
O ken 3ofthc BuMoicia nd Pr&enioraCed0ortM1a he he exempt therefromand
Sn 5 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWI'ICHFSFU(TURES a
O applicant lots permit subjectsthe applicant to a civil penalty&net morethan
$ five hundred dollars($500). NEW RESIDENTIAL FI.ECTR SQ.FT. RIES TYPE CONSTRUCTION
❑1,as owner of the property,or my employees with wag.as their gate k
4 cand Pmaompensation,will dothe work,and thestructure,Is not Intended or offered for
F n sale(Sec.70K Buslocav fessContractive.iore Cade:The Contraors Llarue law
[j3$ docs not apply to an owner d property who Wilds or improv.thereon,and
who doessuchworkhiIfrrthrough hisownemplg.
me ,provided that such OCC GROIII' RFS.UNITS
m
Improveents are not intended oroffered formic.lE however thebuilding or TOTAL:
Improvementbs ldwhhinoneyearofcompldion,theowner-WWerwillhave
not proving that he did nbuild or Improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FOOD ZONE APN
u I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractor's License law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thermn, and who contracts for such pWjecm with a
ryBl�actorE.)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under See. B&P C for this region
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FIX'IUI4F_S TER TRAP SQN_
BOOL TAX Y_
1-11 hereby affirm that I have a amtlReste of consent to self-Wore,or a RECEIPT N
�t.�. ntflestcof Workers'Comperuationtn mnmoramsifiedmpythereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK PER Y N
'.+,b:,,,• 3800,Lab C.)
Policy N RECEBT N
Gore any GAS EA.SYSTEM-OVFRd(EA) BUILDING DIVISION FEES
�Centfled copy H hereby fumlahed. GREASE/INDUS[RL WASTE INTERCEPTORPLANCHECK PEE
❑Cenlfled copy Is filed with the city inspection division. / �3sat�
CERTIFICATE OF EXEMPTION FROM WORK ERS' GREASETRAP PAID6 SfZ
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date RCCCI t#
(Thissection need not be completed If the permit V forons hundred dollars
(Sl(D)or lnsaJ WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
I anifythat b the u rfomance of the work for which this permit is issued,
I shall not employ any person In any manner is,as to become subject to the WATER SYSTEM/TREATING
Workari Compensation Laws of California.Date PAID
0 Z Applicant NEW RESIDENTIAL PIMB. SQ.ET. Date Reeel t#
Z O NOTICE TO APPLICANT.It,after making this CenNate of Exemption,you
should become subject to the WorkersCompematio t provisions of the Labor TOTAL:
N Code,you most forthwith comply with such provisions or this permit shall be
C � deemed mvoked. BUILDING .d
W > conSTRucrIDN LENDING AGENCY SEISMIC FEE a SO
Il E Ihereby affirmthut there is a construction lending agency for the perform- TOTAL:
ELECTRIC FEE
Z onc (Sa
e of the work which this permit Is B.cdc.3097,Civ.C.) PLUMBING FEE
02 Lender's N..
LL 1- Lmdere Address QTY. MECHANICAL PERMIT FE MECHANICAL FEE
U I mnlfythatl have read thisapplicalonand nate thattheabove Information
O W is correct.l agree to complywith all city and county ordinances and gate laws PERMIT ISSUANCE FEES PAID:
r a relating to building construction,and hereby authorlu representatives of tM1b _��-� _6kZ�A)
�
Zcity to enter upon the above�mentloned property for inspection purposes. ALTERORADDTOMECH. Date Receipt#
(We)agree to save,Indemnify an d keep harming the City of Cupertino
V against liabilities,judgments.mks and expenses which may In anywayacrnae AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
.&A. Id City In cocrcx.fthc granting&this permit.
� 2 AIR HANDLING UNLIT(OVER I0,000CFM) C NSTRUCTION TAX
�.---- -Sig reo p Ticar/Contra") p. I —(/� Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applies at or future building occupant store or handle haeardous HEATING UNIT(TO 111,000 BTTI) Date RCCCI t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
ii.lth and Safety Code Section 75537(a)? HEATING UNIT(OVER 100,011 BTU) TOTAL: _
I]Y. M No
Will the applicant or future building occupant use equipment or devices VENTILATION EAN(SINGLE RESID) ISSUANCE DATE
which emit ham rdous air roots minants as deo red by the Bay Area Air
• Quality Management District? BOILER-COMP DHP.OR 100,000 BTU) P A '
'IYea ��'II No
t'r read the h.aQ us materials requirements under Chapter 6.95 of BOILER-COMP(OVEt 100,DDO BTU)
the California Health&Safety Code,Sections 75505,75533 and 2S534.I J •I (D(d �(Ip]�
understand that lithe building does not currently have a tenant,that it E TI
my NEW RESIDENTIAL MECH. UN 1SQ.Fr. u .7.7
responsibility to nosily the oavpant of the requirements which most be met
prior to Issuance of a Certificate of Ottvpancy.
GI IT Ur iaUYcn I uYU
Owner or authorised agent Date TOTAL: ISSUEDBY: �� �-
�� OFFICE COPY