23663 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: _ G36I63/�^/"a('a a"I
m. A A .
CITY OF CUPERTINO4BUILDING DIVISION
c�`neor�nr Li=.Nn7: APPLICATION / PERMIT b
✓ S BUILDINGELECTRICALPLUMBING-MEC11AMCAL CATEGORY CONTROL N
Architect/ grocer. Lk.No:
QTY ELEC17RICPERMIT FEE BUILDING PERMIT INFO
Address:- I'FRhBTI55UANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby t70that[amlkewedunder prsof Chapter9(mmmenc-
APPLIANCES-RESIDENTIAL JOB DESCRIPTION
inSecion on3o(theBuslnessa.dProfesslonsCodeand rtry
lierse1b in u0 forceadd effect.
PANELS
y
Licence Clsss Lk.X Q14"!i(
Date CHIME or l WZ X
ARCNITEGTS DECLARATION OVER00AMPS
re0 Z I understand my plans shah be used u public records. OVER 1000 AMPS _ SQ. R AREA 5/SQ.FT.
q� O
It Z
Licensed Professional SIGNS ELECTRICAL UUM
, IJ i� R
H Q OWNER-BUILDER DECLARATION ^
�i, SI'F.CIALCIRCUIT/M]SC q
po„ a Iherebyaffirm that Iamexempt frand the Contractor's License Law for the
Z 2 Q following reason.(Se tion 70015,Busi a ss and Professions Code:Any city or
Fi"'cy cauntywhichmquU apenNttomwtmct,alter,lmpmve,demolhh,orrepalr TIMP.MEfLRORPOMINST,
any structure prior to Its Issuance,also requires the applicant for such permit to POWER DEVICES
ES file a signed statement that he Is licensed pursuant to the provbiow of the
W60�fF.. Contractor's License Law lChspter9(commencing with Section 7000)of Divi- SWB.iMING IDOL ELECTRIC
VALUATION
F,30J sion 3 ofthe Business and ProfemlordCode)orthat he ls exempt thenefromand
<]]]] the basis for the alleged exemption. Any violation of Section 70613 by any OUTLETSSWITCHF_SF'I%TURFS
applicant for a permit subject theappgcanuo a civil penalty of not more than
c. five hundred dollars(%5M. NEW RESIDENTIAL ELECIR SQFf. STORIES TYPE CONSTRUCTION
❑e sa owner of the property,or my employees with wages r thele sole
ole&c.tion,Buldethe work and the structure brut Intended or..L for
O gale(Sec. pply toanessow andProfessions
property
Code:The ilcia or impctots IAcewe Law
does$ whodot apply torn owner oftprough who nemporlmpronves ovidedreoMand hat such — OCGGROUP RES.UNITS
EEE wes uch work am not
vuelf nded orough Nsowne.If,hoes,p nide ilding or
Improvementsmeiarenosintendedproffered plsale.ILhower-b deer ill have TOTAL:
Improvement lssold wilhimmneyearofcompldlon,theowner-bullderwlll have
tIiLt+Iden of proving that he did not build or Improve for purpose of sat.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
U L as owner of the property,am exclusively contracting with licensed pFRMCT ISSUANCE
contrators to construct the project(Sec.7019,Business and Professions Code:
Tho Cmntddori License Law does one apply to an or of property who
builds or Imprwn thereon, and who contracts for such p(oject with a ALTER-DRAIN&VENT-WATER OW
y4.dor(,)limesed pursuant to the Contractor.License Law. gg0(p(OW PROTECT.DEVICE FEE SUMMARY
LII.m exempt ender Sen B A P C for this reOUTS I
awn DRAINS FLOOR ROOF,AREA,BOND. SANITARY Y_ N_r
t Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTlR2E4 PER TRAP SCHOOLTAX Y_ N_
E31 hereby affirm that I have a certificate of consent to self-Insure,ora RECEIPT N
certificate of Workeri Compensation[nsurance oat certified copy thereo((Sx. GAS F.A.SYSTEM.1 INCA OUTLETS PARK FEE Y N
�oao.licyYb ca /n2.%3 3 3 RECETPTx
GAFA.SYS EM-OVER d IRA)
Cum any _ //. i S BUILDING DI VISION FEES
en
copy is,hereby tumbled. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
Certified copy is filed with the city inspection division.
CERTIFICATE OF E%EMPFION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(fhb setion need not be completed if the permit ls for one hundred dollars SEWER-SANITARY-STORM EA.200FL Date Recei t#
($100)orless.) WATQt HEATER W/VENT/FR.FLTR - ENERGY FEE Y N_
I codify fin
rtify that 1n the pereducco f the work forwhich this permit is issued,
I shall not employ any person In any manner w as to become subject to the WATER SYSTEM/TREATING
Worked'Compensation laws of California. Date PARD
O Z Applicant NEW RESIDENTIAL PLB
M . SQ.Fr. Date RCcel t#
Z NOTICE TO APPLICANT:It,after making this Certificate of Exemption,you
should become subject to the Worker: mns
Copeation provblow of the Labor TOTAL:
N Code,you moat forthwith comply with such provisions orthls permit shall be BUILDING FEE
W >
deemed revoked.
G CONSTRUCTION LENDING AGENCY SEISMIC PEE
CL Z Ihereby affirm that there is cowtmetion lending agency for the perform TOTAL:
S ELECTRIC FEE
arm of the work for which this permit is bound(Sec.3097,Civ.C.)
00 Iender'a Name PLUMBING FEE
F Lender's Address QTY. MECHANICAL PERMIT FEE
LL MECHANICAL FEE
ion
O W Ired.Ihgreet.comly with
alletlmnandetatethattt.roeselnforteis.
C relalsmingt Wildmo comply andtyandmuntyordlnanoesand stateftws PERMIT ISSUANCE PEES PAID:
} U) cityt oenterulPongmabovelon,and Mreopertyby orlurectirmplvn of this
F city to theahove-mentloned properly for Wpe Cit purpose. ALTEROR ADD TO MFGH.
(We)agree to save.IndemNts and keep es which the City of Cu Perrinoaccrue Date Receipt#
V agaWtBabllitim,pdgmenb,nmsand expenm which may In any way amwe AIR IiANDI7NC I1Mf(TO 10,000 CFM) SUBTOTAL:
against said City In consequence of the granting of this permit. CONSTRUCTION TAX
AIR HANDLING UNIT(OVER 10,000 CSM)
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theappllont orfuturc building occupant store or handle havrdous HEATING UNIT(TO 100,000 BTW t Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Tlsalth and Safety Corte,Section 25532(a)i HGTING UNIT(OVER 100,000 BTU) TOTA
❑Yea No
Willthe applicant Ere building occupant use equipment or devices VENITLATION FAN(SINGLE RFSIDI ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management brit? BOILER.COMP(3kN OR 100,000 BTL-0
41�I Yes No P A D
haveread the e us materials requirements under Chapter 6.95 of BOILFR-COMP(OVER IWp00BTU)
the California health k Safety Code,Sections 25505,25533 and 25511.1
understand that if the building does not cumb ly have a tenant,that it Is my NEW RESIDENTIAL MF.CH SQ.FI ��� e9ar
responsibility to notify the occupant of the requirements which must W met I.
p rtolamanceof Cc Pica -of Occupancy.
�LcitjY t- CI'��a K urns
er or authorised agent Date ISSUED BY: N/VV-�� rl
TOTAL:
OFFICE COPY