23803 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
,Building Project Identification PERMIT NO.
Building Address:
2380
CITY OF CUPERTINO-BUILDING IVIS] N rJ
�'j`on�_ /'��a - nne: APPLICATION.,/ P MI
�&I� / er
BUILDING-ELECTRICALPLUM NGM AL CATEGORY CO OIC
Arthitect/Fsgineer. 0 D
QTY ELECTRIC NR T FEE BUILDING PERMIT INFO
Address: PERM[TISSUAN �
LICENSED COensed under
DECLARATION _
T hereby affirm that lam Rcenxd under provisions of Gapter9(commmc ENTAL i OB DFSC
Ingwlthsection7000)of DlWsion3oftheBusinessand ProfesslonaCode,and '
Ilrenx Is In fullfo a and effect C \. 4,
Limn - LICN J
Date Contractor .
ARCHITECPS DE I_Q \ 20. AMPS
2 I understand my plays shag be used as pubbc records ER 1000 AMPS ".FL R AREA $/Sg.
U..
BOO C
Ft,luJ t, Llcenxd Professional - SIGNS EL TRI met, h
G�-Z�r� OWNER-BUILDER DECLARATION SP IAL IR /MISC
L, Ta I hereby afRrmthst l am exempt(romthe Contractor's License Law for the
9•. following reason.(Section 70315,Business and Profemlons Code:Any city or M IR OR POL SI.
p� county which requires apermit oconstruct,alteglmprove,demolish,orrepair
11 a any atrudurepdur ertlshat heeg aLmrequ purtuart to the forauchpermit a D��g
01e a signed gatement that he V licensed pursuant to the proWsiom o! the
Contractor's License (ChapterLaw 9(commencln with Section 7000)of Divl"
3�'•1nRw SWIMMING LELECTRIC VALUATION4'f:
O sion3 of the Buslnessand Profemlom orthat f exempt therefrom and
P.S the iasis for the alleged exemption. Any violation of Section 7 15 by any OUTL SWIICIIESHXTIJRFS 2, 2�
applicant for a permit subjects the applicant to a civil penaltyof net marc than
a OII
R five hundred doarsll (S50m. SQ Fr. S NS'IT CTION
❑I,as owner of the property,or my employees with wages as their sole 7NE RESIDENTIAL ELECTR
2¢ compensation,will do the work and the structure Is not intended or offered for
O sa1e(Sec.7044,Business and Professioro Code:The Contracto/s Llceme Law i
3 Q does not apply to an owner of property who Wilds or improves thereon,and OUI S
who does such work himselforthrough his own employees,provided that such
improvements are not intended oroffered forsale.If,however,thebulldingor
heprovereentissold within oneyearofcomplMbn,theowner.bu derwlll have
lht*rden of proving that he did net Wild or improve for purpose ofsakJ. QTY. PLUMBING PERMITFE TONE APN
LJ 4 as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professlom Code:
The Contractors License Lew does net apply to an owner of property who
builds or Improves thereon, and who contracts fee such puojeas with a ALTER-DRAIN&VENT-WATER(EA)
Ctadorts)urensed pursuant to the Contractor'.urenx caw. FEE SUMMARY
Ll I am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE
DRMNSFLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEII'TN
WOR WAN COMPENSATION DECLARATION 5p{OOL TAX Y_ N_
❑I hereby affirm that I have a rertiBa to of consent to self-Insure,or RECEIPT N
rertlfieste of Workeri Compereation Imearance ora certifext copythereof(See. GAS FA.sYSI'FM"1 INCA OUTLETS PARK FEE Y N
3800,Lab C.)
Policy N RECEPI N
Co any GAS EA.SYSTEM"OVER 4IRA) BUI LUINC DI VI SION PE ES
ffMtRedpy
cois hereby furnished. - CREASE/INDUSRL WASTE INTERCEPTOR PLANCHECI
❑Certified copy b filed with the city Inspection division. q
CERTIFlGTE OF UEMITION FROM WORKERS' GREASETRAP PA _
COMPENSATION INSURANCE SEWER SANITARY-STORM EA 200FI a e Recti TA
(Thin section need not W completed lithe permit b for one hundred dollars
($10()orlese.) WATER HFATFAW/VENT/ELECTR ENEMY FEE Y_
I certlfythat In the perforrranm of thework forwhlch this permit is lswed,
I shall not employ any person in any manner w asme b'd to the WATIRSYSIFM/TREATING -
Workers'Com atlon La 1GR(ornla.D PAID
OZ AppOont 5 NEWRESIDENDALPLMB. SQFT. Date Remi t#
Z O N'OTICETO APPLICANT:If,after making thisCertificate of Ex piton, u
should become subject to the Workers'Compensation provisions fthe r TOTAL:
W Code,you=at forthwith comply with such provisions or this permit shall bea.
lL
BUILDING ITE
J deemed revoked.
CONShat TRUCTION LENDING AGENCY,_ SEISMIC FEE 4
Il Z Thereby orkf rwhicere lsacomt 6Issued dingCSec. 097,0 for the perforrry - TOTAL: ELECTRIC FEE
\
7 Z anceof the work(orwhich Wb permit VLaved(sec.3097,CIv.CJ
O O 'Lender's Name - PLUMBING PEE
IL F LendcreAddress QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I certlfythat l haveread this application and gaethatthe above information �/ FEES PAID:
CL isommct]agree to comply with all city and county ordinances and gate laws PERMIT ISSUANCE
relating to building construction,and hereby autharkee representatives of this
I- N city to enter upon the above-mentioned property for Wpection purposes. ' ALTERORADDTOMECH.
Z Me)agree to save,indemnify an d tree armthe e City of Cupertino - Date Reecipt#
V'
against liabilities,judgments,cog ex n whlchmay in any ay caue AIR HANDLING UNIT(rO 10,10 CFM) SUBTOTAL:
agalminud Ity In on of nt' of thle pemnIt.� -
S AIRHANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
sign ppRE D e EXHAUST}IOOD(W/DUCT) CONSTRUCTION TAX PAID:
mMATERIALS DISCLOSURE
WIIltheap,B n re
,,,rrrrrr
building occupant store or handle hazardous ){EATING UNIT(TO 1ng(00 BTU) Date ROCeI t _+y
mlalthaas Safety by the Cupertino Municipal Code,Chapter9.12,and the 55
Piralth and Safety Code Section 25532(a)7 FIFATINC UNIT(OVER 100,000 BTU) TOT\ .
❑Yes . No
.Will thaappliant or fuwmbulldingaecvpantuxequipr ntordevices VENTILATION FAN(SINGLE RFSID) �IS�UANGG DATE
which emit hazardous air cortaminams as defined by the Bay Area Air
Quality Management District? BOILER-COMP OIE'OR 100,M BTU)
[Rave
I—INo AUG (�p�Q
have rcadtheh. ousmoteCa6requimm nbunder Chapter6.95o(. BOILER-COMP(OVER 100,0000N) 5 1D.7L.
the Califomlx Health&Safety Code,Sections 25505,75533 and 25534.1
understand that if the bu llding does not ev meetly have a tenant,that it ix my NEW RESIDENTIAL MSCI 1. SQ.1T '/s
responsibility to notify the occupant of the requirements which must be ort My Ur �NUrrnIIIT
prior to Issuance of a Certificate of occupancy. .-I\L,
Owner or authorised agent • Date - ISSUEDBY: �/6
OFFICE COPY