23893 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: 23893
10%%S E'(�6 U GTt
wnerme: hone:
tvrwOf^4 CITY OF CUPERTINO-BUILDING DIVISION
contract •.N : APPLICATION /PERMIT � �Z
'• Archllect/Engineer. Lle No: BUILDING-ELECTRICALPLUMBING-MECHANICAL - CATEGORY COI-i7 " -
QTY ELECTRICPERMIT FEE '. BUILDING PERMIT INFO ?.
Address: PFRh1ITISSUANCR �
LICENSED CONTRACTOR'S DECLARATION �.i'{ E] ❑
�
I hereby dorm that l am licensed under provision..!Chspter9(mmmene- APPLIANCES-RESIDENTIAL )OB DESCRIPTION
Ingwlth Sca(on 7000)of Division 3 ofthe Buslncmard ProfeselonsCode,and my s ^ ��{I
Ilcenx Is In full form and effect. PANELS )/Q'C/�
License Cl�y��Lt.M
ate_(7'ti Contractor UP TO 2DO AMM
—LJ—ARCHITECTS DECLARATION 101"1000 AMT'S
otOZ I understand my plans shalbe used as publicrecords. OVER1000AMPS - p SQ.Fr.FLOOR AREAS p $/SQ.FT.
IZ(/ Licensed Professional SIGNSELFLTRICAL FLW,
LED
® B N
6 Gt'1 OWNEReBUILDER DECLARATION B�m �VV
In a SPECIAL CIRCUIT/MISC
[hereby a(flrm that lam exemptfrom the Contractorb Llrense law forth¢
pO following reason.(Secdon 7031.5,Business and Professions Code:Any city or
F Z rter, TFMP.METERORPOLEIN5r.
county eture rcqulresa pemNtto construct,requir.the applicant provry demolhh,errepdr
y any atmeture pnormits Issuance,oho red Exursuardtotheprovisions
t e POWER DEVICES
E� file a signed statement that M h licensed pursuant to the provleloru of the
Contractor's License Law(Chapter 9(commencing with Section 7000)ofOwl. SWIMMING POOL ELECTRIC %`"
f,�Os sion3o(the Business¢nd ProfemlomCode)orthathebeumpttherefromand VALUATION
the bash for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWIMITESFTXTUIRES
applicant for a permit subjectsthe applicant to a civil penalty of not morethan ,
$
if undred dollars($.500).
I,as owner of the property,or my employees with wages as there sole NEW RESIDENTIAL ELECTRSQ.Fr. SIURIES TYPECONSIRUCTION
k and
7a som(Sec.7 KBogner,and mf.loeatructurehn ontracded or offeredLaw
O sole(not 7014,totowner
f property
rope ty Code:The ids or Improves License law
�$ doewhodoesuch toartowner of throng ywhobu mporlmprovvidedes that such
F who doessuch work hlmseUorthr°ugh hlsownemployees,provided thalsuch OCC.GROUI' RES,UNITS
Improvements are nm Intended oroffered forsale.If,however,thebullding or TOTAL:
Improvementbsoldwithin oneyear°fcomplel n,theowner-budderwlll have
the burden of proving that he did not build or Improve for purpose of sale.). QTY, PLUMBINC'PERMIT FEEpLOOD7DNE � APN
L,f 4 as owner of the property,am exclusively contracting with Ikensexi PERMIT ISSUANCE -
contractors to construct the project(Senem a
c.7044,Buslnd Profession Code:
The Contractor's License law does not apply to an owner of properly who ALTER-DRAIN k VENT-WA (EA)
Wild. or Improves thereon,and who contracts for such pTlecie with a
cgB�(actor(a)Bernard pursuant to the Contractor's Llrenm Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B k P C for this re tchQ11T1..1v FEES
Owner Data
DRAINS FLOOR ROOF,ARRA,COND. SANITARY Y_ N
WORKMAN COMP FNSATION DECLARATION RECEIPT N
[—]I hereby af(Irm that I have•rertinate of consent to self-Imre,aro• FIX'IVRFS PER TRAP SCHOOL I"-' Y N
mnln.teofworYen'C.P..H.lm mnmorareAifW copythemof isoc. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE YFDm'Ta
3900,lab CJ
PolicyN CAS G.SYSI'FM-OVER4(EA) RIi EIPr0
Co n4, BUILDING DIVISIONFEES
enNed copyb heed with t ¢city CREASE/INDUSTRL WASTE INTERCEPTOR A CI-IECIC FEE
enlfled copy Let Ned with the city Inspection division. /17'7
CERTIFICATE OF IXEM17T[ON FROM WORKERS' GREASE TRAP A/a- dgg3 � r
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA,4(100FI'. 1 ' Date RCCeI t#
(This section need not W completed If the permit Is forone hundred dollars
(g10o)orlem.) WATER I FFATIR W/VENT/ELECTR ENERGYFEE Y N
I rent em t in oy he any peen i.ce. the work for.t.b this permit is hacted, t
I shall not employ any person In any manner m u to bemnte subject to the WATER SYSTEM/TREATING
Workers'Compensation Lawsof Glllornh.Date PAID .
ZZ NOTICnt NEWRESIDEN'IIAL PLMB. SQrr. Date Recei f#
O
Applicant
APPLICANT U,after making thisCertifiate of Exemption,you
should become subildto the Workers'Compemation provisions of the Labor TOTAL,
tY N Code,you at forthwith comply with such provblom orchis permit shall be BU IN
W ] deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d TherebyaG FEE
fOrmthattherehaconatmebonlendingagencyfortheperform ELECTRICFEE
M Z once.fthcw.,kf.r.which this permit (Sec.3097;CIv.CJ - TOTAL:
O.O I enders Nam PLUMBING FEE
1 . H Lenders Address QTY. MECHANICALTERMIT FEE MECHANICAL FEE
O W
UI certify thatl have readthb application and statethalthe above information
a Lscorreci.l agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. N relating to building construction,and hereby authorize representativesof this _
Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. Date Recei t#
V — (We)agree in save,Indemnify an d keep harmless the City of Cupertino P
against liabllllies,judgments,mats and expenses w yl anywayamrue AIR HANDLING UNIT(TO 10,W0 CFM) SUBTOTAL:
against ealdC In congpquenm of the granti.go t.
SAIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
SI Lure ofA Bam/Comr or to EXHAUST IIOC)D(W/DUCT) CONSTRUCTION TAX PAID:
HAlARD SMATERIALSD LOSURE
Will the applies nt or future building occupan tomorhandlehavrdous HEATING UNIT(TO 100,000 BTU)
moterial..deflncdby the Cupertino Municipal Code,Chapter 9.1$and the Date Reeel
Health and Safety Cude�+.-S�ection 25531(a)? I IrATING UNIT(OVER 100,000 BTLD TO
❑ Yes u No
Will the applicant°rfuture W ilding occupant use equi pmmnt or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminenls as defined bylhe Bay Area Air
Quality Management District? - BOILER-COMP Ohio OR 100,000 ITEM
71 Yea nn No
•- have read the hazardesusm orals requirementa under Chapter 6.95 of BOILER-COMP(OVER 100,(1(10 BTU) pp�� pp pq�
the California Health k Safety Code,Sections 25505,75533 and 15534.1 P A I N
understand that if the building does not currently have a tenant,that it hmy NEW RESIDENTIAL MECH. SQ.Fr
responsibility to notify the occupant of the requirements which must be met � I
1 prior to Issuance of a Certificate of Occupancy, E
Owner or authorized agent - DataNA
TOTAL: ESSUEDCCh(uysJ
OFFICE COPY