23532 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Iderolficatlon PERMIT NO.
Budding Addrc.23'S� o.b ?—s 2 3 5 3 2
weer one:
ate. 1'a� CITY OF CUPERTINO-BUILDING DIVISION
• Contracto�rsNat f ���L�es.N�o: APPLICATION /PERMIT
Ljfts BUILDING-ELECTRICALPLUMBING-MECFIANICAL CATEGORY CONTROL N
ArcAitect/Engineer. Llc.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMIT ISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby thSedirtrmthallamlken3ofthe under
ustnemandPmf sions9(mmmeno- APPEANCFSRFSIDEN7UL �a J00lngwiQESCRR'[I j
licomah ief.11finceol Dlvffect. (the BuslnemandPro/eeclonsCodgand my /,y/��`� /-'_'a\'�t►`�\
license a In fu0 force and erre R. PANELS
License Gen
Date CCrmontractor UP TO 2DOAM5
ARCHITECTS DECLARATION 201-1000AMP5
µQ!Q CO I understand my plans shall be used u public records OVER 1000 AMPS SQ.R.FLOOI�R AREA S/SQ.FT.
E ri Licensed Proresshnal SIGNS ELECTRICAL e ® I\,
Ei OWNER-B TILDERmpt form
DECLARATIONlha.bySPECIAL CIRCUIT/MISC
7 owingrafrirmthallam Licerse Law for the
following rem r.equines a per031.5, o sines and Pmfmbns Code:Any city it
� F' county which requlrnapermittocomtmct,aller,improvn,demolish,orrcpalr TEMP.METER ORI'OhF.INST.
qE anystmcture prior to its Issuance,also mquires the applicant for such permit to
t` DATE_4V
Rk a signed statement that he m Bmosed pursuant to the provisions of the EWER DEVICES
EWS O w Contractor's License Law(Chapter 9(commenting with Section 7000)of Divl-
t,�Os e1..3of the Biudeadand Profmiom Code)ortlut he is exempt themfromand SWIMMING POOL ELECTRIC VALUATION
the basis for the alleged exemption. Any violation of Semon 7031.5 by any
�ggIjj < Eve
for a permit subjects the applicant to a civil penalty of not rrorc than OUTLEISSWITCHFSEXTURFS
6 02 five hundreddollaf hep.(S500. NEW RESIDENTIAL ELFLTR SQ.Ff. STORIES TYPE CONSTRUCTION
ne as mowner of o t property,or my employees In with wages r thele dole
compensation,"I do the work and the s Code:The
V not Intended or offered for
$ O sae(Sec.?ply to alnow and Professions who
builds Contractors hemor,Law
doewhodormuch for hinnerorprupertyersigh whobulldsorimproves
ovidedthat and OCC.GROUP RES.UNITS
CC.. whodoementsa orkhimsededoroffemdow formic.
If,however,
rovWedthatsuch
Improvementsarenot intended earofco (weak.IShowevepthebulldingve TOTAL:
Improvement Imld prowlwithin he did of completion roe for puposerwillh.).
tl(9,) Lasrdeowner
of the phevrty,not build orlmpmveforpurpne ofeale.). QrY, PLUMBING PERMIT. FEE p(-OODZDNE APN
Ltr4ad ownertrthe property,(S exclusivelyBusiness and
ingwithns Coe: PERMIT ISSUANCE
The Co trd to construct the.doe(See 7014,Business and Profmior t Code:
The Contractors Lice&the Taw don not apply to an owned of property who ALTAR-DRAIN&VENT-WATER MM
builds or Improved thereory and who contracts !or each pRvpcte with e
c,Ilt dor(s)licensed pursuant in the Contractor's Llnme Law. ` FE&SUMMARY
LII am exempt under Sea B&P C for this mason BACK FLOW PROTECT.DEVICE
DRAINS PLOD ROOF, SANITARY Y NOUTqIF_
FEES-
Owner Date R AREA,GOND. - RECEIPT N
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm certificate that 1 have a of consent to self hours,ora FU('NRFS PER TRAP SCHOOL TAX Y_ N
NN
udificateof Workers'Compematlonlmuranwaracert(fkdmpythemof TE . R 3800,Lab C.) GAS 11
PA. INCA OUTLETS PARK PER Y N
Policy N — RECET N
I
Com GAS EA.SYSTEM-OVER 4(EA)
any BUILDING DIVISION IT[S
Certified copy ld hembytumecity GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy m tiled with the sly Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCESEWER-SANITARY-STORM FA 200FT Date Rewi tM
(Dissection need not be completed If the permit L+frn one hundred dollars
($100rmlees.) WATER HEATER W/VENT/E.ECTR ENERGY FEE Y N
(certify thatln the person In
for t-be is sub)ts to
—
I shall not employ any person In any manner n m m become subject to the WATER SYSTEM/TREATING
' Workeri Compenvllon Gws o(Callfornla.Date Fplp
O Z Applicant - Date Recei IN
Z 0 NOTICE TO APPLICANT:14 cher making this Certlficateof Exemption,you
NEW RESIDENTIAL PLMB. SQ.hT.
Fshould become subject to the Worken'Compensrtlon provisions aflhe Labor TOTAL:
y Code,you most forthwith complywlth such provisloruorthb pemdt.hdlbe
deemed Invoked. U
W
G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby.M mthat there is a construction lending agency for the perform ELECTRIC FEE
Z ance ofthe work for which this permit is Issued(Sec.3097,CIv.C.) TO
U O Lender.Name PLUMBING FEE
LL F Lender.Addrem QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I cedlfylhatl have read thisappllmtionand statethat the abovelnfor d.
bcermct.Iagreeto complywithall dtyand rountymrdinancnand mate laws ( PERMITISSUANCE �� FEES-PAID:
} N
relating tobutlding construction,and hereby authorlu mpersentatives ofthis
(— Z city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,Indemnify an d keep harmless the City of Cupertino Date ReceiptN
V against liabilities,judgments,rostsand expenses which may In any way same AIR HANDLING UNIT CTO 10,000 CFM) SUBTOTAL:
against Bald City In consequence of the gra sting of this permit.
ALR HANDL(NG UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Data FXHAUS'T HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haeardous HEATING UNIT(TO 100,000 BTU) Date Reeei tH
material as defined by the Cupedino Municipal Code,Chapter 9.12,and the - aarrkkttf�
Health and Safcty Cade Section25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTA a..�
❑ Yes r]No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESLD) ISSUANCE DATE
which emit ha ardous air contaminants as defined by the Bdy Area Air PAID
D
. Quality Management District? BORER-COMP OFI'OR 100,0(10 BTU) N"
4teriYrs 4 No
have read the haza sus ma
als requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the Gllfernla Health&Safety Code,Sections 25505,25533 and 25534.I APR 201992
u nd custard that if the be lldeg don not curmotly have a tenant,that it is my NEW RES[DENTIAL MECH. SQ.FT
responsibility to not 11y"ha p..t of the requeements which must be met Ty�s/� C�7v
prior to issuance of a Cert]RmOccupancy.te of Occupancy. C\M(L— UfGini Cry llfyLd
Owner or authortud agent Date
TOTw ISSUED BV�S
OFFICE COPY