23263 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
gull IngiAd sS 23263
,
am: one: APPLICAHUN SUDMIIIAL
r. CITY OF CUPERTINO-BUILDING DIVISION
conName: Lk.No: APPLICATION /PERMIT
BUILDING-ELECTRICAL PLUMBING-MECH N7CAL CATEGORY
CONTROL M
Architect/Engineer. V Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO .
Address,ere 1 PE4h0T155UANCE .I ❑
LICENSE.CONTRACTOR'S DECLARATION I_
7 hereby
firm that HX B1 3 funderprovlslone of Ch.'...Cde,aAd c- APPLIANCFSRESIDENTIAL JOB DFSCRU'110N
IngwlthSMlo(k7000)of Divlalon3otthe Business cad m(eaelonsCode,andm
license le in 1 deffett. S PANELS
Date Contndor —UP TO 200 AMPS
CHITECFS DECLA ATION 201-IODO AMPS
q�v 9Z (understand my plans shall be used as publicrecords. OVERIOOOAMPS SQ.FT.FLOOR AREA S/SQ.FT.
Fi� Licensed Pmfesslueal SIGNSELECTRICAL
M«<< OWNER-BOLDER
e
BLDER DECLARATION
fir
f" Thereby a
ntlutlam exempt from the Contractor's License Law for the S['ECIALCIRCUIT/MIST
ZO...� following....(Section 7031.5,Buslnessand Professions Code:Any dtyor t
OZ TEMP. ORPOLE(NST.
F county whkhrequlmapertNtrocor,etmd,iltep lmpmve,demoWh,orrepilr f,''— F1
'y a anystmmmpr toibbmance,al mqureatheappRantforsuchper tto POWER DEVICES _ ( "1,1' L
K V file a signed statement that he b licensed pursuant to the provisions, the - I
3cc�. Contractor's License Lave(Chapter 9(commencing with Section 7000)of Diet. SWIMMING Poo,ELECTRIC bV u
�Og slon3ofthe Buslnessand Professions Code)orthat hebesempttherefromanLUATI N
Gthe basis for the alleged exemption. Any violation of Section 70315 by any OUTLETSSWUCHES-FIXTURES -`E /
applicant fora permit subjects the applicant to a civil penalty of no more than
five hundred dollars($500). NEW RESIDENTIAL ELECTR L
❑I,as owner of the property,or my employees with wages as their sole �'�' 57ORIES TYPE CONSTRUCTION
7a compensation,wllldothe work.andthestrudurebn_t intendedor offered for
O sets(Sec.7044,Business and Professions Code:The Contractors License Law
does not apply to an owner of property who builds or Improves t hereon,and OCC.GROUP RES.UNITS
who docsauchwork himself_rthr_ugh hisown employees,provided thatmch
Improvements are not Intended oroffered forsale.If,however,the building or - .►�
Improvement bsold withlnoneyearofcompletion,the owner-builderwW have
tl),JFrden of pmvlRgthat be did nm build or Improve for purpose oleale I QTY. PLUMBING PERMIT FEE FLOODZDNE APN
LJ I,as owner of the property,am exclusively contracting with licensed
contractorsro cerstract the project(Sec.7Uk Business and Professions Code: PERMITISSUANCE
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN&VENTWATER(EA)
Wilds or Improves thereon,and who contracts for such pAom - -jewith a - —
cador(s)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEl7CE FEE SUMMARY
LJ I am exempt under Sec. B&P C for thin reason
•
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_Owner Date Rp�p N
WORKMAN COMPIiNSATION DECLARATION FDCrUR1SS PER TRAP SCIi00L TAX Y N
hereby affirm that I have a rertmcele of cement 10 aeu-comm,or ��Q�,M
Ali rate of orken'Com roatlonlnsurana aracertifled mpythemof(Sec. . GAS EA.SYSTEM-]INCA OUTLETS PARKFM Y_ N_
policypoli lab / / -G/j
Cffp �✓s' -71( RECm'I'x
Com env ill O AA GAS EA.SYSTCM-OVER4(EA) HUILDINGDIVIMONFI:ES
�Ce edcpy[�ercbyth the cid. GREASEANDUSIRL WA5TE INTERCEPTOR PLANCHECK FEE
ettified copy b(fled with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.2DOFT. Data Recei t#
(This action need cad h completed((the permitb - -
!.'cone hundred dollars '
($100)_rlsss.) WATER HEATER W/VENT/ELCCTR ENERGY FEE Y N
I certify that In the performance of the work for which this permit is issued,
I shall net employ any person In any manner so as to becons abject to the WATER SYSTEM/TRFAUNG
Workers Compensation Lawsof Ca W_rd..Date PAID
O Z Applicant
NEW RESIDENTIAL PLMB. SQ.}T. Date Recei t#
Z Q NOlicant APPLICANT.If,after nuking fhb Certificate of Exemptionyou
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
It y Code,you must forthwith comply withsoch provblonsorthb permitshall be
deemed revoked. - BUILD •E
dCONSTRUCTION LENDING AGENCY SEISMIC FEE
Iht.byal0rm that there b a construttion knelugagency for the perform ELECTRIC FEE
Z ance ofthe w_rkf.',which this permit is Issued(See3097,Civ,C) TOTAL:
fJ O Lander.Name PLUMBING FEE
LL l— Lenders Add QTY. MECHANICAL PERMIT FEE MECHANICAL FEE ^—
O W Iudlty
'ham A ereadthb epplicetlon and etatethat the abovebefonn"Bon
incorrect.]a t comply
with a"
cttyand countyordIranone andstatelaws PERMIT ISSUANCE FEES PAID:
IL relatingto Ildin co coon,and hereby authorize representatives.'!this
Zcityro eN upon ve-menllor,ed property(w inspect,_.purposes. ALTERORADDTOMECH. Date Recei t#
_ (We) a to n'sme"y an d keep harm—the City of Cupertino P
agabstl bllltle rate,caste ends sea which may lnery ova c5me AIR HANDLING UNIT ITE 10,000 CFM) SUBTOTAL:
against Id Ci 1 it
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA2aA R DOUS MATERIALS DISCLOSURE
Will the a ppbmnt or future bu Oding occupant store or handle hazardous HEATING UNIT(TO 100,000 RTU) at Recei t#
material as defined by the Cupertino Munkipal Code,Chapter 9.12,and the -
liealthandSafetyC_tle Section 25532(a)7 HEATING UNIT 100,000 BTU) TOTA �'^'
Y. M NO
Will the applicant or future building occupant use equipment or devices VFNHLATIONFAN(SINGLERFSID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Arca Air
Quality Management DisMd7 BOILER-COMP OHP OR 100,(X0 BTI)
4 Yes No Eq
have read the has trao.terials requirements under Chapter 6.95 of BOILER-COMP(OVIR IDQ000BTU) r
the Cxlifernla Health&Safety Code,Sections 25505,25533 and 255M.I
understand that lithe building does not currently have a tenant,that it be my NEW RESIDENTIAL MECH. SQ.FT _
responsibility m cad ify the occupant of the requirements which must be met {u/ 'i
prior to Issue are of a Certificate of Occupancy. 1
Owner or authorlud agent Date -C�ll IIV11
lUTAL:
OFFICE COPY