23056 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification 7 PERMITNO.
Budding Address: 17� 23056,
era ante: e:
errs rq- CITY OF CUPERTINO-BUILDINGDIVISION
c adorrName: Lic.No: APPLICATION /PERMIT
•V♦ BUILDINGI.ECTRICAL-PLUMBINGMECHANICAL CATEGORY CO
Architect/Engineer. Lk.No:
Q1Y ELECTRIC PERMIT FEE,
PERMIT INFO
Address: PERNETISSUANCE �� LJI
LICENSED CONTRACTOR'S DECLARATION L.�
Ihereby affirm that l am licensed under provisions of Chapter 9(comment, APPLIANCFSRFSIDENTIAL J gDF5C122tgQPH N /
Inense1Semon to.af leffeon3a(thc Businneand Professions Code,and my ars / Plata
license is Ins; force and effect. PANELS .11�� ` 1
LicenseClaes Lk.p
Date Contractor `[�•�(�
ARCHITECT'S DECLARATION 2011000 AMPS, t
OZ I understand my plamshall be used as public records OVERI000 SQ.FT.FLOOR AREA E/SQ.FT.
OpO
]U Licensed Prodmakmal SIGNS EL AL 1 �O
that
I=exempt
DECLARATION SPFAL >7KSC `
owmgnxamn.(hatlam31.5,B from the Contractors Code:icense Law fort he
following reason.(Sesame 7m1$Business and,improve,
Code:My city t, TEMP.M LE I
s"
county which reapmiresa permit issuantocowtequires theapmvent forslah,ormitto
qqq any structuretatemeitrhathecgabosedpursuaapplicant fonuch permit to ICES
O (Ile a signed statement that he t Bcensed pursuant to the provtlons of the
3w Contractors License Law(Chapter9(commencing with Section 7W0)ofDivi-
�03 slon3o(theBualnnsandPro(emb®Code).rihatheisexemptthemfmmand WwMM G ELECTRIC VALUATION
6 the basis for the alleged exemption. Any violation of Section 7031.5 by any, unrns- FIXTURES 06a "�•/
applicant fora permit subjects the applicant to a civil penalty of not more than
five Nuns ed ownerlof thepr. NEW RESIDENTIAL SQ.FT. STORIES TYPECONSfRUCT10N
�n
1,as owner a(the property,or my employers with wages as (fere for s.
compensation,Busio the ness
andwork fand
xsxmCdumhe is Contactor or License
Law r
P O sale(does Sec.
apply to ainowandf property
Code:The or improves
License Law
jr$ whodolapply loan owner olp rough whobuilds nemorlmpmovidedrees,andatsuch R 5
whodonsuch
uts am nhimselftintdad or o through blown employees,provided building
uil that such
Improvement arenotithin one earofcomr offered caseate.If, owner-buildervall have D' Nil,
P -
improvement 0eoldwithinoneysarofcompldloM theowner-WBderwlll have v i IJ�
rdenof proving that he did not Wild or improve for purpose ofnle3, QTY. PLUMBING PERMIT ' FLOG as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE f10
teacton/o occurred the project 7044,Business and Pro(eolons Code: I. D TE
I Cantrader's License Law does not apply to a,.owner ed property who ALTER-DRAIN&VENT-WATER(EA)
Wilda or Improves thereon, and who contracts !o each peojeds with a
X.
etastor(s)licensed pursuant to the Contmeter's License Law. BACK FLOW PROT[CT.DEVICE FEE SUMMARY
1,-J I am exempt under Sec B k P C for this reason
Owner DRAINS FLOOR ROOF,AREA,CONI. SANITARY Y N
Date RECEIPT X
WORKMAN COMPENSATION DECLARATION pIXNRES PER??Lisa SCHOOL TAX Y N
❑I hereby affirm that I have o ce Insurance
of consent to opytheure,ora �~ RECEIPT X
ce00,Labrtificam of Worken'Compenealimnlvuranco oraunified copythemrof(Sec. __ GAS EA.SYSTEM-]INCA OUTLETS PARK FM y N
3XOQ Iris C.)
C. X ASIA.SYSTEMOVER
RECEITM
Com any BUILDINGDIVISI
Mottled copy t hereby filed
dwth the cid. EASE/INDUSTRL WASTE INTERCEPTOR PLA FEE
❑ ottled copy tfliedwith 1M city inspection division.
.,ASE TRV'
CERTIFICATECOMPENSATION
N FROM WORKERS' PAID \
COMP[NSATIONINSURANCE
(This section need not be completed Blhe permit t(orone hundred dollars TARY-STORM F.A.2001rT. C 2CCel [q
(S1IX)orfytha WATER HTF /VENT/ELECTR ENERCY FEE Y N
(certify that Inthe performance of the work brwhlch this pe rod tksued, —
I shall not employ any person In any manner sons to become subject to t e TR SYSTEM P
s- Workem'Compensatlonlawsof Call(omb.Date PAID
Z
PP NEW D AL FT. Date 1 NOTICETO APPLICANT.R,.fmreeking thisCertificateof Exemption,You
tq
Fshould become subject to the Workers'Compensation provisions.(the Labor TOTAL:
CCN Code,you=at forthwith comply with such provisions orthii permit shall be EUI _
deemed revoked.
W � ' CONSTRUCTION LENDING AGENCY SEISMIC FEE
d IherebyalBrm that there t a construction lending agency for the perform` ELECTRIC FEE t
Z ante ofthe work(or which this permit b Wued(Sec.3097,Civ.C.) `_ ELECTRIC EE �-•
02 lenders Name
LL ~ lender',Addreaa QTY. MECHANICAL PERMIT 'FEE MECHANICAL FEE r�
U I cortirythat l have read thtappllcatlonand statthattheabove Information
O W Iscorred.I agree to complywith all city and county ordinances and datelawsPERMITISSUANCE �� FEES PAID:
>- 1 relating to building cowtructirm end herebyauthamserepersomativesofthls
W city to enter upon the above-mentioned property for impaction purposes. ALTER OR ADD TO MECH.
? (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receiptlf
V agaimtlabliltiea,judgment,cortaandexpenseswhkhereyinanywayaccrue AIR HANDLING UNITITO 10,000CFM) ��. SUBTOTAL'
against said City in consequence of the granting of this peAIR HANDLING UNIT(OVER 10,( ()CHN) CONSTRUCTION TAX
Si o(Appliont/Contractor gg 27 � EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant store or hand le hazardous I HEATINGUNITO'0100,000 BTU) Date RCC ri
material as defined by the Cupertino Municipal Code,Chapter 9AZ and the 1 -
I
Health and SafetyCode Seaton 25532(a)? HEATING UNIT(OVER 100,000 BTU) T
❑ Yea -,No
Will lheapplicard oPture building oavpant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hazardous air contaminants a,defined by the Bay Area Air py
Quality Management District? BOILLR-COMP OHF OR 100,OM BTU B- A, ' D
4Yrs n No
havereadtheh..Qusmaterials requireminsunder Chapter 6.9iof BOILER-COMP(OVER100,000BTU)
the California Health&SafetyCode,Sedions25505,25533and25534. I FEB 251992
understand that lithe building docs not currently have atenanq LS]
that It is my NEW RDENTIA?.MECH. SQ.I7
responsibility to notify the occupant of the requirements which most be mat /�
prior to issuance of a Certificate of Occupancy. CITY UI- UUrrn I ow
Owner or authoromd agent Date ISSUED BY:
OFFICE COPY