23250 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proea Identification PERMIT NO.
Building Address: - 23250
nen ame: Sv N K O-0 . one: A
CITY OF CUPERTINO-BUILDING DIVISION —7� �j Z
Contractors me: ��i��� Lic.No: APPLICATION I PERMIT
BUILDING-IIECTRICAL PLUMBING-MECIIAMCAL CAh-GORY CONTROL M
Architect/EngitW n. Lk.No:
*QTY ELECTRIC PERMIT FEE" BUILDING PERMIT INFO
Add. SGJ r PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am llcnsed under provisions of Chapter9(commere APPLIANCES-RESIDENTIAL JOB DESCRIPTION
inarea ISection Interned affeon3otthe Busineseand�fnsionsCode,andmy � �
Bcenm Islafu0 Interned .# 44S-3
/ -3� PANELS
� License Clam LICM 'N p
Date CHITECTS DEC ATI N T � 701-IMOAMPS
aOZ I understand my plana shall be used as publicremrda OVER 1000 AMPS SQ.FT.FLOOR AREA 5/SQ.FT.
F.
Fi Licensed Professional SIGNS ELECTRICAL
< OWNER•BUILDER DECLARATION
�n�o SPECIAL CIRCUIT/MISC
09 Iherebya((irmthatlam exempt from the d Pnectoree Code:
LawAny cit or
O =ntyngreason.(SMio.7 tW Bms dandprofessions Code:Anympair
F i"� county which requlrnapemNltocowtroct,alter improve,demolIsh,orrepalr TEmP' GI'FR ORPOLE INST.
anystructure pdorto Its Issuance,also requlrestheappllnnt forsuch permit to -
Cntractor's License Law(Chapter I r I' i!
(� file a signed statement that he Is licensed pursuant to the provo ons of the POWER DE'VI FS
(EyyOw o
G1;DG'i " J
f, elon3o(the Husinessand Profemloru Code)orthat hebexemp[therefromand SWIMNgNC _LELECIRIC � ) VALUATION ,
the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLE SWITCI{FSEXTURFS `
appilant for a permit subjectsthe applicant to a civil penalty.a sea more than
a 0 flue hundred delta.ofthe M.pro a RIES TYPE CONSTR[KTION
j'9..'.. ❑I,as owner.(the property,or my employers with wages as their soleal R D LEf .FT.
on penaatlon,willdothe workand the structure Is not Intended or offered for
C p6
&c.70K Busi....d Profemiore Code The Contnector'.Licecue Law '
3� does not apply to an owner of property who builds or Improves thereon,and
EEE who dnessuch work himself orthmugh hisoed wn employees,provided that such OCC.CROUP RIS UMTS
Improvements are not Intended orotfered foreale.If,however,the building or TOTAL:
Improvement u sold within oncyearofcumplalon,the owner-builderwill have
04tlurden of proving that he did not build or Improve for purpose of sale.). QTY PLUMBING PERMIT 'FEE rLCCD ZONE APN
Il L as owner of the property,am exclusively contracting with licensed PERMITISSUANCE r�
contractors to constma the project(Sec.7040,Business and Profesums Code:
The Contmesorb Limrue law don nM apply to an owner of property who ALTER-DRAIN&VENT•WATER(EA)
Wilds or improve them..,sort who contracts for such pk jeers with a
+ctor(s)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
Lf I am exempt under Sec. B k P C for that reason
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY V_ N
• Owner Date RECEBrTp
I WORKMAN COMPENSATION DECLARATION FIXTURES I'ER 7RM SCHOOL TAX Y N_
❑T hereby affirm that I have o certlfk of consent t.self-Insure,ora RECEIPT p
3800,Ub�Aifimteof Worken'C.mpemaHon ln.unna ora certlfled copy lM1ereof(Sec. GAS FA.SYSTEM-1 INCA OUTLETS PARK FFP Y_ N
3600,lab CJ
PolicyM RECEIPT
C. GAS EA.SYSTEM-OVER BWLUINC DI V
ISION FEES
m Cyfied copy It hereby te
Certified copy Is filed withh the city
inspection division. GREASEANDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
ity
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCESEWER-SAN.TARYSIDRM EA 70011. Date Recei !p
(Thlssecil.n need not W completed lithe permit Is(prom hundred dollars
(§100)orfy that
WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Illnw thato theppemnannny of workfar to thisp wbo Issued,
I shall not employ any person In any manner ao as to berome nubject to the WATIM SYSTEM/TRFATING
Workcra'Compensatlon laws o(Califomla. Date PAID
O Z Applicant
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PWB. SQJ-7, Date Recef til
N should bemmesubret to the Workers'Compercation pmvbiom of the Labor TOTAL:
Code,you crust forthwith comply with such provisions orthis permit shall be
LU > deemed revoked. BUILDING LU g CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency for the perform- ELECTRIC FEE
M Z ante of the work for which this permit I.it.rd(Sec.3097,Cia:C.) TO
U0 leder'.Name PLUMBING FEE
LL F- Lender'.Addrem qTY. MECHANICAL PERMIT "'FEE MECHANICAL FEE'
O W lcertifythati have read thhappliratlonand statethatthe above information
bcomect.Iagreeto complywith all city and county ordinances and nate laws PERMIT ISSUANCE FEES PAID:
IL relating to building construction,and he rebyauthorlurepmanntativesofthIs
1— Z city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harndem the City of Cupertino Date Reeei tit
O
against Liabilities,pdgments,mutated expenses which may In anyway accrue AIR HANDLING UNIT(TO 10,M0 CFM) SUBTOTAL:.
agamld City in� sepuenre 9f the granting of this permit.
•/1/.CI_C� AIR HANDLING uNrr(OVER la,mocFh+> CONSTRUCTION TAX
SlgmtureofA pit t/Contractor Date D(HAUSTHOOD(W/DUCT) - CONSTRUCTION TAX PAID:
1 AZARDOUS MATERIALS DISCLOSURE
Will the applicant orfutum building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Dale Recef !N
matcrlal ere defined by the Cupertino MuNdpal Code,Chapter 9,17,and the
Hnilhand SafetyCode Section25537(a)7 HEATING UNIT(OVER 100,000 BM TOTAL.
❑.Yes No
Will the applicanlor uture building compant use equipment ordeviccn VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which cost hazardous air contaminants as defined by the Bay Area Air
. Illy Management District? BOILER COMP OTB'OR 100,0(10 HIM p
a Yae ❑❑No A
have read the hazallous materials requirements under Chapter 6.95 of BOILER-COMP(OVE{100,000 BTU)
the California Ilealthh Safety Code,Seetiocu 25505,25533 and 75534.1 ._-� 1992
understand that it the building don not currently have a tenant,that It Is my NEW RESIDEMIAL MECH. SQ.FT ED
rnpoasibllity to notify the occupant of the require mentswMch must be ma FEB
prior to issuance of aCertiticateof Occupancy. f Cl1l Iplij
CffY �r
Ower,miuthorimd a gent Date ISSUED BY: _"'" �� vC•
TOTAL:
OFFICE COPY