23626 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildin Pro'en Identification PERMIT NO.
Building Address: 2 3 6 2 6
Ve 2.
nus �. � I CITY OF CUPERTINO-BUILDING DIVISION
cant (,a�l1� APPLICATION / PERMIT
BUILDING-ELECTWCALPLUMBINGMECHAMCAL CATFLORY CONTROL N
ArchltM/Engineer. Lk.Na
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ ❑ � ❑
LICENSED CONTRACTOR'S DECLARATION
Iherebyaffirm that l am hcrosed under provisions of Chapter9(commenc APPLIANCESRFSIDENTIAL ]OB DESCRIPTION
ingwith Section7000)of Di"sian3ofthe Businensand Pmfo msCede,and my
license is in full innocent]affect. 7 PANELS
LiameChss _ LICN e713 r
ate Contractor U cA rUP TO 21st
ARCHITECTS DECLARATION 2014000 AMPS
002 I understand my plans shall be used as publicremrds. OVERIODOAMPS SQ.FT.FLOOR AREA $/SQ.FT.
W
U U Licensed Professional 9CN5 ELECTRICAL
<� OWI am ex NLDER DECLARATION LED I N
I-n GZ SPECLILC6(CUfT/MISC
�O.., y owing r asons.(hat l am 31.5,Bxempt fromBusiness
a Contractor's License law for the
OZH following reasons. 7031.5,Business and Professions Code:Any dtyor TEMP.METER OR POLE INST.
-county which nyulrosa permit to constvct,alter,improve,demolhh.orrepair P UTE R
q anystrucnrre pdortoitsbsuancealsormulreatheappBant forsuchpermltto POWER DEVICES vi
t5 file a signed statement that he is licensed pursuant to the provisions of the
3aG ConlraRors License Law(Chapter 9(commencing wish Section 7000)of Dial. SWIMMING POOL ELECTRIC ATION
O sion3ofthe Bus essandPMeriom Code)orthathehemm themfmmand
M
the basis for the alleged exemption. Any violation of SIon 7031.5 by any OUTLETSSWITCHGSFIXTURES
appllant fora pencil sed)seetheapplicant too civil penalty dna more than
e. o five hundred dollars($SOOT NEW RESIDFNITAL ELECTR
1 s owner of the employees with wages as their sole �'�' STORIES TYPE CONSTkIKTION
a property,or my scop oy g
pG compensation,will do the work and the structure is net Intended or offered for
O sale(Scc.7064,Business and Professions Code:The Contractors License Law
� $ don not apply to an owner of property who builds or improves thereon,and OCC.CROUP RIS.UNffS
4 whodoeseuch work himselforthrwgh hisownemployess,provided thatsuch
improvements are not Intended unaltered for sale.If,howeem thebuilding or TOTAL:
improvement lssold within oneyearaftempletion,ths owner-bu0derwill have
t!)9kurden of proving that he did nat build or improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed PpRMI'TISSUANCE
JOE—
contractors to constrad the proyct(Sec.7M4,Business and Professions Code:
The Contractors License Law don net apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon, and who contracts fee such pto)ects with a FEE SUMMARY
cg0t{aRor(s)Ikenxd pursuantrothe Contractor's Llanae Law. BACK FLOW PROTECT.DEVICE
IJ I am exempt under Sec B&P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEIPT#
QI hereWORKMAN COMPENSATION DECLARATION PER TRAP SCHOOL TAX Y_ N_
by affirm that I have a certificate of coven to self-Iusam,ora RECEIPT N
certificate o(Workers'Compematton Insurance ora certified copy thereof(Sec. GAS EA.SYSTEM-1 INC OUTLETS PARK FEE Y N
38Is 00,Lab C.) RECEIPT N
Policy N GAS EA.SY6TEM-0VER 4(FA)
Cam any - BNLDINC DIV]SION FEES
[�Cscifled copy b hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
0 Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORK ERS' GREASE TRAP PAID
COMPENSATION INSURANCESEWER-SANITARY-STORM E.A.200FT Date RCCei t#
(rhlssectlon need not be completed If the permit in forone hundred dollar
(610BOrlcea) WATER HEATER W/VENT/EI.ECTR ENERGY FEE Y_ N_
I artily that in the performance of the wok for which this permit is issued,
I shall not employ any person in any manner se,as to become subject to the ATEI+.SYSCFM/ EATING I^P
Workeri Compensation Laws of California. Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQJT. Date Recef t#
ZO NOnCETO APPLICANT:If,after makingthb Certdlateof Exemption,you
should become subject to the Worker%Compensation provisionsof the Labor TOTAL:
fp Code,you swat forthwith comply with such provisions orthh permit shall be I BUILDING FEE
deemed revoked.
W a CONSTRUCTION LENDING AGENCY SEISMIC PEE
d Ihereby affirm that there is a construction lending agency for the perform T ELECTRIC FEE
M Z ante ofthe work for which this permit is Lssued(Sec.3097,Cia.CJ PLUMBING FEE -�
V O Leader.Name
LL I- Lendars Addrens QTY. MECHANICAL PERMIT FEE MECHANICALFEE
O I1U 1 certifythat I have read this application and state that the above information
is carrel.l agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
T relating to building construction,and hereby autharas representatives ofthis
F city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
(We)agree to save,Indemnify an d kap bareness;the City of Cupertino Date Receipt#
2
V
against liabilities,Pcigmenh,causand expenses which nuymanywayaanae AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against d City in consequence of the ming of this permit.
-9i AIR HANDLING UNIT(OVER 10,1100 CIM) CONSTRUCTION TAX
(Signature of Applicant/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding occupant store or handle havrdous HEATING UNIT(TO 100000 BTU) Date Rece) t#
material as dented by the Cupertino Municipal Code,Chapter 9.1 2,and the -
I Iaith and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL.
❑ Y. M No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUArjCFrDbTE
which emit hazardous air contaminants as defined by the Bay Area Air
Qu lity Management District? BOILER-COMP OHPOR 100,000 BTU)
11Y" ❑No MAY - 5
havercadtheha>allousmateria6mquimm nKunderChapter6.95of BOILER-CO-CON _U) 1(1(1
the California Health&Safety Code,Sections 25505,2W3 and 2SSM.I IAO
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ17T. CIIY
Lair-
responsibility to notify the occupant of the requirements which must be met Uf kaVl'Cf1111YV
prior to issuance of a Certificate of Occupancy.
Owner or authorized agent Date ISSUED BY:
TOTAL:
OFFICE COPY