23393 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Idvntiflcmionass C � PERMIT NO.
Building Address: O
0'5'5'5 TLt� �vt��u ez- 23393
area: one: APPLICATION hUbMII IM,
nano 2 'S—3"2Z CITY OF CUPERTINO-BUILDING DIVISION O
Contr LIc.No, APPLICATION / PERMIT -
• � �' - BUILDING-ELECTRICA1,PLUMBING-MEC C CATEGORY CONTROL.
Architect/Engineer. Llc.N.
QTY, ELECTRIC PERMtr, FEE A _
BU ING PERMIT INFO
Aaare.. /LL V L rFxl.RnsSUANGE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm thatlam ncen.ed vnderprovhlona of Chapter9(mmmonc APPLIANCES D JOB DESCRIPTION
IngwhI I fon7000)of defalon3ofthe Buelneuandl'rofesalonsCode,and my �`�
Iigwift ectionf deme p /
License• no LicR 1 'CJ
Date "4.—Contractor C:lPFVC_Q&j 11
ARCHITECT'S DECLARATION 201- AMPS
µQS a0 O[ understand my platy stallbe used u public records I .FLOOR AREA
f/SQ.FT.
E5 Licensed Profesicrul SIGNSELECTRIC
Q OWNER-BUILDER DECLARATION 'CAZC / jago
Iherebyafl.that l am exempt from the Cmaractorb Limns lawforth.
O
following reason.(Section 7031.5,Business and Professions Code:Any city or
TEMP.MET� POLE INST.
F� caunty wit Ichedclum requlreI.perMttomarequires the aprovgdemonah,armit ir to
anyatmcture prior tolb Issuance,also requlrcetheappllcent(or.uch permit to POWER CES s"1 6�J
O file a signed statement that he Is licensed pursuant to the provisions of the l•
wG Contractor's License Law(Chapter 9(mmmencing with Section 7000)of Divi- NG IA70L ELECTRIC
O aloes 3 of the Bucineuand Profenlo®Code)or that he is exempttherefrom and VALUATION
O the bash for the alleged exemption. Any t tolatlon of naltlonet
by anyun UTLETS-SWITCHESFIXTURES O may( V
pG$Jj apeBundredfora ollars aubjeatsthe applicant too civil penalty of rad rrorethan Y vv
live hundred dollars(i50W. NEW RESIDENTIAL ELECTR SQ,FT,
�n ❑I,ac owner of the property,or my employee.with wages as their sole STORIES TYPE CONSTRUCTION
tempo...if.,wnldothe work And theatructure Is nod Intended or offered for
O sale(Sec.7044,Business and Pro(eslom Code:The Contractors License law
3� does not apply to an owner of property who build@ or improves theme,and
who doesauch work himself mthrough Msown employes,provided that such
Improvements am not Intended or offered for sale.If,however,the building or 7 T
Improvement is sold within oneyearo(completion,the mener-builderwfll have .. ,,,
Baku rden of pmeing that he did net bunF
d or Improve for purpose of sale.). QTY: PLUMBING PERMIT EE '
LI,as owner of the property,am exclusively contracting with licensed pPERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code: a^
The Contractor's License Law does not apply to an owner of property who ALTER-DRAM&VEM-WATER(EA)
Wild-or Improve.thereon, and who contract.for such ptokct.with a
CgR([actor(s)licensed pursuant to the Contractor's Lkens Law. gA�plpytr pgU•ppLT.DEVICE.
(_J I am exempt under Sec B& P C far this rcuan'
Owner DRAINS-FLOOR ROOF,AREA,COND. SANITARY Y N•
Date RECEIPT p
WORKMAN COMPENSATION DECLARATION
ak� ❑T hereby affirm that 1 have a certlnase
te of consent to self-insure,or a `2.. FIXTURES'PER TRAP /' SCHOOL TAX RECEIPT_ NM
3800,Lab C.)
cenlflateofWorkeri Compensation Insurance or o certified copy thereof(Sec. GAS EA.SYSTEM-1 WC.40IIILEIS PARK FEE Y N
-
Policy M RECEIPT a
Com GAS EA.SYSTEM-OVER 4(EA)
Y BUILDING DIVISION ITiiS
CedlOed copy h hereby(umhhed.
rifledCREASE/INDUSIA).WASTE WTERCEI'TUR PLANGHECIC FEE w-(�
•Cil Cecopy h filed with the city inspection division. �
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID ___S ,y
COMPENSATION INSURANCE SLWER-SANITARY-STORM EA.200Fr. Date Recei [N 7i
(This seniors need net
be completed lithe permit(.(Drone hundred dollars
(f100)orlces3 WATER HEATER W/VFM/ELCCTR ENERGY FEE Y N
I certify that N the performanaof the work for which this penult is blued,
I shall not employ any person In any manner m as to become subject to the WATER SYSTEM/TREATING
Workeri Compensation Laws of California. Date PAID
ZZ Applicant NEW RESIDENTIAL PLMB. $Q.FT. Date Recei tN
0 NOTICETO APPLICANT.If,after making thisCertifiateof Exemption,you
hshould been.subject to the Workers'Comp...ti.n provbimaof the Labor TOTAL'
N Code,you most forthwith comply with such proviams or this permit she]l Im
W > deemed revoked. - - G
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a G IherebyafRrtnthat there h a natructim lending agency for the perform ELEGTRIG AEE
Z once of Rise workforwhichthls pe mdtbh.ued(Sec.3097,Civ.C.) 79
U O Lenders Nan¢ PLUMBING FEE
LL H Iender.Addres. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I cedtlyihallhave read thlsappllcatlonand statethatthe above Information
IL isrorrect.I agreeto comply withal]city and county ordinances and state laws PERMITIS5UANCE FEES PAID:
IA relating to building constroctian,and herebyauthorim representatives o(this '
(_ Z city to enter upon the above,mentioned propcny for iuspectlon purpose. ALTER OR ADD TO MECH. ZE
Date Recelpfk
(We)agree to save,indemnify an d keep harmless the City of Cu ped Ino A[R HANDLING[IMT(I'010,000 CFM)against nablBtles,jodgerenta,mw-and expenea which may lnanywayaccrue SUBTOTAL:
against said Gly Inconsequence of the granting of this parsnip
AIR HANDLING UNIT(OVER I g000CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor - Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAUR DOGS MATERIALS DISCLOSURE
Will the appnca rat or future building occupant store or hand to hazardous HEATING UNIT(TO 100,100 BTU) Date R2cC1 [N
material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the -
HealthandS.fetyCadSection 25532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes No
Will the applicant o uture building omrpanl use equipment or devices VEMILATTON FAN(SIN GLE RESID) �... ISSUANCE DAT(.
which vend ha rdous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP 0HPOR 100,000 BTU)
n Ve. No
P `f'havercad the haz�tyCodeiahrcoonr underChapter and 255M. 95 of MER-COMP(OVER 700,000 BTU) A
the Gltandt Health&Safety Code,Sections25505,ve.tand,that I
understand that if notify
the onupant notcurrentlyrremiyment,tenant,that b hay MW RESIDENTIAL MECII. SQFI. ��� �� ����
r I.,toibnity tonotify the occupant o(the mqulrcmenls which'muat be rrad
pC1for to1 Lssuanc// (a�QIe,d]f(�(�p,aa�J((eofOm an G v
IV'IIY�l.1Ra'�IT.CL/O+wry. G,Z �_ /. 1'VI 1111`1U
O&nen or authorized agent te V Da1 ,
7'O ISSUED BY:_
OFFICE COPY