23804 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Prole ct identification PERMIT NO.
BuildingC_d ms,: ` 23804 .
ss r.
WntraOnt:
Q y11 5 CITY OF CUPERTINO- ING DIVISION
C 'a Name: LIc.Na APPLICATI UI PERMIT
Arc '� —�
' � ( BUILDING-ELECTRIC L UMBING-MLCHAIJICAI; CA7 V- CONTROLp
lte /Fengt •� a�("�L� i
�? .OTT ELEC I P MIT FEE' BUILDING PERMIT INFO
UL ELELI .1-1,11M13 MbLil
Address: fV�l 14 _
PI3ihRTI 1'5•t }�
Lm that ED CONTRACTOR'S DECLARATION
Ihereby
ection mthatl Bernardunder
usmassandsafChapter9(commrnc AI'PI.IA DE JOB DESCRIPTION
Ingwhh Sedron force andldied.3o(the Buslasand Profeslont,Cade,and my
license Is In full force and effect. PA
Ii nns�Clag .Llc.p T e D -`e
ate Lic.N Ii loll.• (i/
10 ARCHITECTS DECLARATION2 AMI
0 Z I understand my plans shall be used u public records. O 1000 AM SQ.Fr.MODE AREA 'S/SQ.Fl.
uG 7J 6
�j Licensed Pmfemlonal SIGNSELECTRI AL ,..aA
6 OWNER-BUILDER DECLARATION (�
�a SPECIALCIRCUI /
Zqv owing rasimt.( atla7031ABfrom the Contractor's Wanse Gycityw for he or
❑❑ followinhichre.(Se Uon70315,Busineuand Professions Code:Anydtyor
F t'ey countywhich rcqulrcsa permitrocoatact,alter,improve,demolIsh,orrepalr TEMP.M LE INST.
7 any strudom poor to its Issuance,also requires the applicant for such permit to
K 5 file a signed statement that he Is licensed pursuant to the provIslons of the POWER D S
3w Counicturs License Law(Chapter 9(commendngwith Section 7W0)ofDivi. SWRdMING LELECTRIC
F O sion3 ofthe Business and Professions Cade)orthat he it exempt therommand VALUATIO>j
YI the basis for the alleged exemption. Any violation of Section 7BILS by any1 d D(f
applicant for a permit subject,the applicantr
to a civil penalty of not nrethan OII7LETSSWI7CHESFLYTURFS `
five hundred dollars($SOO. NEW RESIDENTIAL ELECTRSQ.FT.
�n ❑I,as owner of the property,or my employees with wages as their sole STORIES TYPE GDN5IRDG77DN
e7Q
compensation,will do the work and the structure Isnot intended or offered for
N O rale(Sec.7064,Business and Professions Code:The Contractors License law
does not apply to an owner of property who builds or improve thereon,and OCC.GRCUP RES.UNITS
0.0. who doest,uchwork hlmselforthrwgh hlsownemplgees,provided thalsuch _
improvements are not Intended oroffered forsale.If,however,thebullding or T
Improvementlssoldwithto oaycarofcompletiorytheowner-bullderwlll have
tl�urden of proving that he did notbuild or Improve for purpose ofsale.). QTY. PLUMBING PERMIT "FEE FTAOD_ZONE APN
j,_j 7,as owner of the property,am exclusively contrading with licenced ppgMlT ISSUANCE
oontiactoee n,to construct the project(S 7044 Busines and Profesioa Code:
The Contractor's License law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or improves thereon,and who mention, for such plojeds with a
'gp([actor(s)Bmnsed pursuant to the Contractor's Lianse Law. BACK FLOW PROTECT.DEVICEFEE SUMMARY
LJ I am exempt under Sec B&P C for this morin
OUTSID
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N ,
Owner Date RECEIPT p
WORI(MAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y_ N_
3800,Lab C.) S
❑I hereby affirm that I have a arttf tate of consent to sell-Insure,ora RECEIPT M
cenifimteo(Worken CompematlonlmuranmoraaAlfWmpythereof(Sec. GAPA.SYSITM-1 INCA OUTLETS PARK FIB Y N
A RECEIIrI'q
GAS EA.SYSTEM-OVER 4 IEA) BUILDING DIViSION FEES
tied copy Is hercbyth the ity - GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEEfletl copy Is(Ileo with the city inspection division. TOO
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP P
COMPENSATION INSURANCE SEINER SANITARYSTORM EA 200PT ne Recei t#
Rhissection need not be completed lithe permit Is foram hundred dollars `
%lMorless) WATER HEATER W/VENT/ELDCTR ENERGY FEE N O •(�
I artlfy that In the performance ofthe work forwhich this permit is Issued, —
I shall not employ any person In any manner w at,to become subject to the WATER SYSTEM/TREATING
Workeri Compensation Laws of California Date PAID
-
Z Z Applicant NEWRESIDENTIALPLMB.__SQ.Ff. Date ReC i i#
Z O NOTICE TO APPLICANT.ILafler ma king this CertificateoHixeroptlon,you
Hshould larom .nibject to the Worker'Compensation provisions of the Labor DIAL: P
f/3Code,you must forthwith comply withsuch provisions orthis permit shall be> deemed revoked. D NG FEd CONSTRUCTIONLENDINGAGENCY SEISMIC FEE Ihercbyafflrmthatlhere Iso comWction lending agency for the perform TOTAL: ELL•CTRICFEE
Z arses.ftheworkforwhkhthlsrn Rt Wued(Bec.3097,CIv.C.IO O LandersNmae PLUMBING FEE
LL F- fanderb Address QTY. MECHANICAL PERMIT .FEE MECHANICAL FEE
O W I.difythatlluvereadthbapplicatlonandstatethattheaboveinfornution
Is correct.l agree to comply with all city and county ordinances and state laws Pr"ITISSIZANCE FEES PAID:
} 4 ,relating to buliding corowctlon,and hereby authorlu rcprcsentativee of thIs
Zcity to enter upon the above-mentioned property for Inspection purposes. ALTIRORADDTOMECH. Date Recei t#
_ (We)agree to save,indemnify an d keep harmless the Clty of Cupertino
agabst e,judggme ,co rd mue
expenses which may in any wayaAIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
g.or raid Ci n era of egranting.(this permit.
-q^ AIR HANDLING UNIT(OVER IO,ODOCr•M) CONSTRUCTION TAX
Signature of Appilcant/Contractor Date ` EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or ha cad In haaardous HEATING UNIT(TO 100,000 BTU)
ma - Date RCCCI i#
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the -
I feallh and Safety Cade Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
M Ye No
Will the applicant Rom,building occupant use equipment or devices VENTILATION PAN(SINGLE REBID) ISSUANCE DATE
which emit haaardous air mora Mnanb as de(lad by the Bay Area Alr
Quality Management DlsW07 BOILER-COMP OHP OR 100,IX0 BTU)
Yea ❑j''�No ® y
havercadthehaaartlousmaleriaisrequimm maunder Chapierb.95of BOILER COMP(OVER 100,000 BTU) P
the California Health&Safety Code,Sections 25505,25533 and 25511, 1 JUL W�g
understand that ifthe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.1T. Q
reaponeibility to notify the occupant of the requirements
which=at be met •i`C/
prior to issuance of a Certificate of Occupancy. City /
Owner or authartred agent Date b ft `TZIK I Ilyu
3 ISSUED BYV d
OFFICE COPY