23652 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
-Building Project identification PLRMITNO.
,
Building Address:
23652 3 6 5 2
wner�rante: one: G u{ �hAJ G
'� CITY OF CUPERTINO-BUILDING DIVISION T��.�
contract°' IN@1me` Ge. APPLICATION / PERMIT J �*'l2.
—��GPTV /1G.aCJILW JRUILDINGELECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL a. .
Architect/Engineer: Llc. o:
Q7Y• ELECFRICPERMIT, FEE, , '
t'BUILDING PERMIT
IINFO
Address:. PERMITISSUANCE. I,�Iiu,u,,,A
LICENSED CONTRACTOR'S DECLARATION LJ' El El
I hereby affirm that l am licensed under provisions of Chapter 9(commenc- APPLIANCESR—ES DENTIA.L J08 DGSCRE''f10N
inense Is in
7Sindivhlon3oltheBusines+an�[' ! onaCade,andm 1�`
license is In full( end effect. !'133 (,�6 ., • PANELS
i.icense ChatLk.M .
Date_y/YConefaalor hAN
V ARCHITECTS DECLARATION 201-1000 AMPS _
N 2 I understand my plane shall he used as publlc records, OVER 1000 M 5. SQ.Fr,FTADR AItEA - S/SQ.FT.
Q0,.
pWw. Cl� Licensed Profc id rot SIGNS ELECTRICAL +'
-]4 ku OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC • - `
h'yd:.tat Iherebyaffirm that lam exempt from the CmAractor'.Licenm law for the -
oo qq fallowing reason.(Section 70115,Business and Peafession+Cade:Any city or
FZH 'county which requires a permit m ccraM1un,sheq improve,den'olhh,orrepair 7EMP.METERORPOLEINSC
°"1 33 anystmmmpol toibl ance,alsonquimstheappllmntforsuchpermitto
(� file a+Igned statement that he h licensed pursuant to the provIums of the ROWFR DEVICES.
3w Contractor§License Law(Chapter9(commencing with Section 7000)of Dlvl- SWIMMING IDOL ELECTRIC
BOJ slon3oftheB..fa....d Professore Cade)orthathehexempttherefromand VALUATIO f�
Sn the basis for the alleged exemption. Any violation of Section 703L5 by any
<� app r.rtfor.penvg.ubjecatheappllcanttoa civil prealtyofnat menathan OUTLETSSSWITCHESH ES'
five hundred dollars(SSW).
n1,as owner of the property,or my employees with wages as their sole NEW RESIDENTIAL ELFLTR SQ.FT FS _ 7YPECONSTRUCTION
C < compensation,will do the work and the structure h not intended or offered for
O sale(Sec.70K Buslnme and Professlore,Code:The Contractors License Law
does not apply to an owner of property who builds or Improves thereon,and
OCC GROUT' RFS'UNITS' '
whodoessuchwork himsellorthmogh hisownemployees,provided that such
Improvements are not intended oroffered formic.If,however,thebuilding or pL:
Improvement lswld withinoneyearofcompletlog theowner-bu0derwill have
IIg�Nrden of proving that he did not build or Improve for purpose ofsale.), QTY, 'g_ PLU/NBINGPERMIT• , •E FIgODZONE APN•
"I,as owner of the property,am exclusively contracting with licensed .0
ISSUANCE to mretruct the project(Sec.7DK Business and Pmfeasle.Code:
The Contractor's License Law does net apply to an owner of property who ALTER-DRAIN&VE
builds or Improves thereon,and who contract for each p ojem - NT-WATER(EA)with a
911 ` FEE'SUMMARY'
S(+ctorte)Rmrcse
nd pursuant to the Contractor.LicenLaw. x -
LJ I am exempt under Sec B&P C for this mason BACK FLOW PROTECT.DEVICE- - '
Avner Date DRAINS FLOOR ROOF,AREA,CONT. SANITARY Y_ N
WORKMAN COMPENSATION DECLARATION. - RECEIPT=
[31 hereby affirm that I have•certificatens
o!consent to self-Iureor a FIX'IURF_4 PER TRAP SCHOOL TAX Y N'
Jcertlliente ofWorkers'Compemationln+uranmoracedifie mpythemof(Sce. RECEIPT
`^ 3800,Lab C.) GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y . N- _
Policy It RECEIPT'M
Cam any - GAS.EA.SYS EM7 OVERd(EA) BUILDING DI VIS NPEES
MCertlRed copy h herebyfurnished.the city CREASE/INDUSFRL WASTE INTERCEPTOR PLANCHECK FEE
MCertifled copy lafiled with the city Inspection division. -1 �
CERTIFICATE OF EX EMPTION FROM WORKERS' GREASE TRAP PAID l v
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.�2WIT. - Date Remi tN
(Thlasectlon need rad be completed if the permit hfor one hundred dollen �^J
(El W)orlenJ WATER HEATER W/VENT/ELECTR IKX FEE Y N .
Ill notrtify thatlnthe performance work this is rr
Isbell not employ any person pct any manner n u to become subject to the WATER SYSTEM/TREATING
Worken'Compensatlon laws of California.Date ' 1 ID '
O Z Applicant
Z O NOTICETO APPLICAto too, mks.' irig CettlficateofmooftExemption,aLx1ho
NEW RESIDENTIAL PLMB.__SQbT, Dile Recei IN
Code, ou=aforth it the Warkei%Cush proatmns orthle parmuhe Lab or gkERM . TOTAL:
NCWe,you mustforthwith comply with such proWiom orthh pemNt+hall be �la j deemed Invoked.(LES CONSTRUCTION LENDING AGENCY - S I PI hereby orkfo w ichthem hammtl Issuden lendingagency 7,Civ. the pnr(orm u 0 anceoflhe work(or which thh permitlahsued(Sec.3097,CIv.CJU ¢nater.Name P M81N PEE
Iy F dersAddm+ QTY. MECHANICAITE MECHANI L F EEOWI certllythat l have read this applicatlonand statethat theabovelnf.mllon -C l+romci.lagreeto comply with aBcityand county oldlnanceaand state law+ PERMRISSUANCEPEES PAID
} W reittegto building coretructlon,and hereby authoroe,representatives ofthls ,
F Z city to enter upon the above-mentioned property for inspection purposes. ALTEROR'ADDTOMECH. Date— (We)agree to save,indemnity an d keep harmless the City of Cu Paul Receipt#
against liabilities,jutlgments;cons and expenses which may In any way acerue AIR HANDLING NIT CFO 10,000 CFM)
againatmm By conuiue aft granUngoflhi.pennit. - SUBTOTAL:
AIR HANDLING IJNTT,(OVEN lO,WO CIM? CONSTRU ON TAX
'gnat. PER.'
re EXHAUSTHOOD(W/DUCT CONSTRUC ON TAX PAID:'
HAZARDOUS MATEqq LSDLSCL SU ' ,
WII applim ntorfuturcbulldbgoLn'pant store or handle hazardous IIFATINGUMT(T0100,"BTU) - t
DBfC RCCCIUf
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the - - I _
i leabh and Safety Code Seco..25532(a)2 HEATING UNIT(OVER 100,000IVEM • `
Yes No71
Will the applicant or future building occupant use equipment ordevices VENTILATION FAN(SINGLE RESID)'" ISSUANCE DATE
which eMnaement airrict? arab a+de0ncd bythe Bay Areu At,
Quality Management District? BOILER-COMPOH'OR 100,iXq BTU)
Y,- No
Thave read the haa.QusmaterialsnNulrementsunderChapter6.95of BOILER-COMP(OVER 100,003 BN)
the Callfomla Health&Safety Code,Sen lona 75505,25533 and 25534.I PAID
u ad units rad that If the building does not cvrmntly have a tenant,that it is my NL'WRINDEMIALMECH fQ.Fr.
prior toissily to nallythe o ate of ofthe requlrcments which most be met
prior to issuance ofa Certificate o(Occupanry.
fd'H e
Ownerorauthonudagent - Date
TOTAL: ISSUPDA, .
OFFICE COPY