23851 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm'ec Identification 7 I'UWT NO.
Building Address: rs-a--1 23851_
laz�v #Pula �/i's7xl
wnere ane: one:
n�rcS �/ 4-n-o CITY OF CUPERTINO-BUILDINGDIVISION / ^
Co�n//77a a eName: Lie.No: APPLICATION / PERMIT ,r ( (/
cv�L r �- 376a 7 BUILDINGELFCTWCAGPLUMBING.MECHAMCAL CATECARY CONTROLN
Architect/Enginse Lle No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE 1:1 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affbmthat l am licensed under provisions of Chapter 9(commenc. APPLIANCMRESIDENTIAL JOB DCSCRIPTION
ingwlth Section 7000)of DiNsion3otthe Businewand Pmfe onsCode,and my
license Is In f dl force and effect. PANELS
Llocr��rrr����Cl������eeeeee Lic.M G ��FL
Date
—Contractor 2011 We AMPS
UP TO 200 AM
ARCHITECTS DECLARATION OVER 1030 AMPS �1 FT.FLOOR AREA $/SQ.FT.
qa0 O I and stand plans shall W asci n public records. Fes' 1'sa
q��vv C SIGNS ELECTRICAL V
k ly(] Licensd Professional
<Q OWNER-BUILDER DECLARATION I n Ij
In FnSI'[CIALCB2CUIT/MI9C
ffiB 1
1.., Iherebya .nthatlam exempt Contractor's License lawforthe
following reason.(Section 7Bi1.5,Business and Professions Code:Any city or TEMP METER ORPOLE INST.
K �., muntywhlchrequbnsapermirust,al
ttommttcr,ImpmvelB
,de= hormpalr
11 .a anyslrueure priortolts issuance,also requlresthe applicant forsuch permttto POWER DEVICES
file a signed statement that he is Ilansed pursuant to the provisions of the
p0� Contractor's License Law(Chapter 9(commencing with Section 7(00)of Divi-WMVALUA'ilQ�05 slop 3 of the Busin....di Professions Code)or that he h exempt therefrom and SWIMMING POOL ELECTRICCom...
the basis for the alleged exemption. Any violation of Section 70315 by any OUTLEISSWITCHFSFIXTIIREH
applicant for a permit subjects the applicant to a civil penalty of not more than
$
five 1,as ed owner of hepr. NEW RESIDENTIAL ELECTR SQ.FT. S[OWFS TYPECONSLRIXTION'
�j.. ❑e s,owner of the property,or he employees with wages r thele..In
k7Q cempensatlon,wllldolhe workand thestructumbrwt intended.coffered for '
y p sale(Sec.7064,Business and Professions Code:The Contractors License Law
does not apply to an owner of property who Wilds or improves thereon,and OCC.GROUT' RIS.UNITS
who does such work himself or through his own employees,provided that such
Improvements are not Intended or offered for sale.If,however,the building or TOTAL:
Improvement is sold within oneyearofcompletbn,the owner-W Oderwill have
tY,,V1,
on of proving that he did na build or improve for purpose of este.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ as owner of the property,am exchudively contracting with licensed PpRMpf1SSUANCE
contract..to construct the project(Sec.7064,Business and Profession Code:
The Contractor's License Law does not apply to an owner d property who
Wilds or Improves thereon, and who commets for such p(ojects with aALTER-DRAIN&VENT-WATER(EA)
coy(actor(s)Emoted panus.to the Contractors License Law. FEE SUMMARY
L,j 1 am exempt under Sec. B&P C for thin mason BACK FLOW PROTECT.DEVICE
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N—
. Owner Dale RECEIPT p
WORKMAN COMP a cSATION DECLARATION FD(TURES PER TRAP SCHOOL TAX Y N
❑1 hereby affirm that I have•certificate of consent to se14wre
1n ,ora RECEIPT 0
ceeltiateo(Works.'Compensationlmunnmuracedif4 mpythereof(Sec. GAS EA.SYSTEM.1 INCA OUTLETS PARK FEE Y N
3800,Lab C.) C —
PoB e q10.'C_7,16%` /Z ens EA.SYSTEM-OVER 4(FA) RECE=T p
Com aey L[iLt B U IL DING DI VI SION FEES
gertlfled copy b hereby furnished. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
❑Certified copy is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE $EWER-SANITARY-STORM EA 2001,-T Date RCCCI [N
(This section need not be completed B the permit is for one Fund red dollars
($100)or inn.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
1 certify that In the performance of the work forwhlch this permit is hsud,
I shall not employ any person In any manner an as to become mbject to the WATER SYSTEM/TREATING
Workers'Compensatlon Laws of California.Date PAID
OZ nppilmt NEW RESIDENTIAL PLMB. SQn. Dale Recei Iq
Z O NOTICETO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation proalloreof the Labor TOTAL:
N Code,you most forthwith comply with such provisions or this permit shall be BUILDING FE —77!
K j denmd revoked.
W — CONSTRUCTION LENDING AGENCY SEISMIC FEB _
d I hereby affirmthat there V a construction lending agency for the perform- TOTAL: ELECTRIC FEE
Is 7 Z ance of the work for which this permit iud
u (See 3.97,Civ.C.) PLUMBING FEE
00 Icnder'eName
LL F Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I metltythatl have read thbappliatlonand sta,ethattheab.ve Information
IL u cornet l agree to comply with all cityand county ordlnanms and slate laws PERMIT ISSUANCE FEES PAID:
T relating to building construction,and hereby authorize representatives of this
H Z city t.enter 'Pont ab.vementloned property for inspection purposes. ALTER OR ADDTO MECH. Date RCCCIPtiF
(We a to save,Indemnify an d p harmiess the City of Cupertino AIR HANDLING IJMT UO 10,030 CFM) SUBTOTAL
V again 1 Iltim,rydgments, oan� cmc., chmayinanywaya.0ue
agal , d Clty In conseq f 6 ant his pemtit.
a 6./ r AIRHANDLING UNIT(OVER IQ"CFM) CONSTRUCTION TAX
gntureo plies omra r Wt EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
RDD SMATERIALS DISCLOSURE
Wlll,h appli or future building occupant store or handle hazardous HEATING UNIT(10 100,ODO BM Date Recei tN
materUl as defin y the Cupertino Municipal Code,Chapter 9.12,and the
Hcalthand Safcty Cdn Section25532(a)2 HEATING UNIT(OVER 100,000 BTU) TOT L.
❑Yes MN. VWfILATION FAN(SINGLE•RESID) ISSUANCE DATE
Will the hamou air
emhang occupant use equipment ordevices
whichlily strut Management
ate contaminants as defined by the Bay Area At, (�
Quality Mangement Distrlct7 BOILER-COMP Q11PGR 1 W,IXp BTU)
4Yesn No
havereadthe In..qusmaterials requimmentsuoder Cha pter6.95of BOILER-COMP(OVEti100,000 BTU) JUN 17 19
the California health&Safety Cde,Sections 25505,25533 and 25534.1
unde.Wnd that lithe Wilding does not currently have a tenant,that it 4 my NEW RESIDENTIALMECH. SQ.FT
responsibllity,o notitythe occupant of the requirementswhich must be met CIIT Up. VI s 7. ,..4t
prior to Issuance a a Certificate of Occupancy,
Owner or authorized agent Date ISSUED BY:
TOTAL: �fL�yLa'-i
OFFICE COPY