23628 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bhlldin Project Identification PERMIT NO.
Building of a C;PbWrvue 23628
As �Namt:� //�$ $� one: A A
/SCI CAA h 725-- 83% CITY OF CUPERTINO-BUILDING DIVISION
c traiiw: C��.. No: APPLICATION I PERMIT
�1G a`� BUILDINGELECTRICAInLTMBINC-MECH LAICAL CA'fF1-ARV CONTROL#
Arc �glneer. Llc No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address
LICENSED CONTRACTOR'S DECLARATION PERhIITISSUANCE 1:1 1-1 El
I heam ivRce underprovisions or Chapler9(rommmc APPANCESRESDENTIAL
ingwlthSrdk.n7000)ofDivision3ofthe BuaiessuandProfssonaCode,and my JOB DESCRIPTION
license is in(uI and effect. PANELS
Lice
license 1.
# .x'161 9 O y LZ 1
Date ContraRor UP TO 2DO ANTS
ARCHITECTS%CLARATION 701-1000 AMPS
7O, un Ice lawa I sednspub11 rds. OVEKl000AMPS _ .FT ARPI
Lic sed Professional - SIGNS ELECTRICAL ^ Raaf
L 1`�
<� OWNER .Fact
BUILDER DECLARATION SPEMLCIRCUIT/MLSC
t.. L Thereby arm exempt xempContractor'sromthe Contractor's License law for the
p (O
0�@ following...(SMion 70315,Business a nd Prons feeloCode:Any city or gyIT
TEMP.MER OR POLE INST.
� QE
county which requlrcsa permittomwtrua,alter,improve,demolish,orrepair
gg any atmdure statement
It that he is licensed pursuant
to the revisions;of t e POWER DEVICES
file a signed statement that he le licensed pursuant to the provisions;of the
8 Contractor's License Law(Chapter 9(commencing with Section 7000)of Divl- SWIMMING POOL ELECTRIC
ston3 ofthe Business and PromseionsCode orthat he is exempt therefemand VALUATION
the basis for the alleged exemption. Any violation of Section 70315 by any O OUTLETSSW7ICFIFSHXTURFS
O w
� OS appBmntfora permit subjects the applicant to a civil penalty of not morethan
c. Ove hundred dollars($.500).
NEW RESIDENTIALELECTR STORIES TYPE CONSTRUCTION
?�n I,as owner of toe property,or he employees with wages r there sole �'�'
compensation,willdothe Business aworkaProfteadons Code: his nmintendedo iofferedfor
a0 sale(Sec.apply
to Business owner
of Property
who
or imp
wes Ucense law
$ does not applytork owner ofproperty who nImporimprovesthereon,and OCC.GROUP RFS.UNITS
whodoessuch
isami himself or eclorough his ownempioyev,provided that such
Improvementsarcnot Intended earofred(orsale.I(h er-q Oder ldingve TOTAL:
Improvement bsoldwithin ow ycaro(completbn,theowner-W Oderw0l have
t4t1sardenof proving that he did nabuOdorimproveforpurpoaeofsals.). QTY, PLUMBING PERMIT FEEFLOOD7ANE MN
Lj 1,as owner of the property,am exclusively=trading with licensed PQ4MTT ISSUANCE
contractors to constrot the project(Sec.7014,Business and Profeasiow Code:
The Contractors License Law does not apply m an owner of property who ALTER-DRAIN VENT-WATER ffN
Wilds or Improves thereon, and who contracts for such ptojets with a
cq➢_t[aaor(s)licensed pursuant to the Contractors License Law, BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B& P C for this reason
OUTSIDE
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RECEIPT'#
E31 hereby affirm that I have a mti0ate of consent to self-insure,or a FD(TURES PER TRAP SCHOOL TA% Y N_
mtifimte of Workers'Compewatlon Insurance or a certlf ed copythereof(Sec. RECEIPT#
3800,Isis CJ GAS EA.SYSTEN I WC.4 OUTLETS PARK FEE Y N
Policy# RECEIPT a
Co any GAS EA.SYSTEM-OVER 4(EA)ffCertlOed ropyV hereby furnished. BUILDING DIVISION FEES
❑Certified copy Is filed with the city Inspection division. CREASE/INDUSIRL WAS FE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF UEM PTION FROM WORK ERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(fhissetionneed not Wcompited ifthepermitufwonehundreddollars SEWER-SANITARY-STORM E.A.200FT. Date Recel t#
($100)or lens.)
I cetlfythat In the perfomanceofthe work forwhich this permit is lseard, WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
I shall not employ any person In any manner sou to the
Workers'C t1 La fCa11(ar la Daterr _ WATER
SYSTEM/TREATING PAID
O Z Applicant ` o '.r U
Z O NOTICE TO AI'I'I.ICANT:I,after making this Cetifkate a(ExempLon,you NEW RESIDENTIAL PLMB. SQ.FE Date Reeei t#
Fshould became subject to the Worken'Compensation provisions ofthe Labor TOTAL:
WN Code,you must forthwith mmPly with such provisions orchis permit shall he
> aorema revoked. - BUIL ING E'E ^
aZ G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that them to a construction lending agency for the perform- ELECTRIC FEE
ance ofthe work for which this permit 0 Issued(Sec.3097,Civ.CJ TOTAL:
U O Iender'sName PLUMBING FEE
1L F Lender's Addrew QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Irertifythatl have read this appBatbnaM matethat theaboveinfomaHon
a 6corret.I agree to comply with al city and county ordinance and mate laws PERMUISSUANCE FEES PAID:
} N city
toe nobupongconslmctiogaMhtreby authorize rcprexn purposes.
of[his
F Z cityW)aree to ave,he indemnify
property for Wpetloty purposes. ALTER OR ADDTO MICH.
—
(We)agree to judgments,
Indemnify an d keep harmiess the City of Cupertino Date Receipt#
aga tBabtlities,judgmenb,comsand expenses which may In any wayacoue AIR HM,IDLING UNIT CFO 10,000CF ) SUBTOTAL'
.gal Sala Cit ronaequenm off ung o�thle permit AIR HANDLING UNIT(OVER 10,MOCE,) CONSTRUCTION TAX
5�6�9 z
Signature of Appliesnt/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or ha fid Is hazardous HEATING UNIT(TO 100,"BTI)
material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the _ Date Reeei t#
Ilea Ith❑ Vend Safety Code,Section 25537(a)7 HEATING UNIT(OVER 100,000 HIM To
Will the applicant or❑future building occupant use equipment or devices VFNDLATION EAN(SINGLE RF"D) ISSUAN!!lTTT nATE
which tout hazardous air contaminants.,defined by the Bay Area Air �I-E B
Quality hlansgement District? BOILER-COMP OLI'OR 100,000 BTU) 6/
Ihave mad the ha,alr7�ousmaterials requirements underChaper6.95of BOILER-CO MP(OVEi1W,000BN) �I11AY ' a 1992
the GOfornia ldcalth&Safety Cod,Setiom 75505,25533 and 75534.I
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECIT1 SQ.I-F.
responsibility to notify the occupant of the requirereents which moat W met
prior to issuance of a Certificate of Occu pa nry. CITY Ur t/UI'Ctf I INU
Owneror authorised agent Date /)
TOTAL: ISSUED BY:
OFFICE COPY