23296 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildingProject Identification PERMIT NO.
Build Ing AEdresa:s •/rr , 23296
�JetT/r/�. arm: /: /j one: APPI1CAr6R3(E87, nT_AU=A
L" - CITY OF CUPERTINO-BUILDING DIVISION P�
out., LIc.Ne: APPLICATION /PERMIT
lee/` loci}' —7 BUILDING-ELECTRIcALPL -MECHANICAL CATEGORY CONTROLIf
^ Anclued/Engineer. Lk.N.
\ QTY ELE ERMFF FEE BUILDING PERMIT INFO
Address: �,s�' // K PER?ATI ❑ ❑
LICENSED CONTRACTOR'S ISECLA ATION
Ihereby affirmthat l am licensed under provisions of Chapter9(' mmen RESIDE OBD R�'fION
Ingwith Sedton700Wof DiWson3oftheBwinessand Professions w Z
Bunnse lC ss l�i(o eand(o ce and c.# o,
Llanse Class LION �
Date
Contra
ARCHITECTS DECLARAT ON 701-I
qp O 7O I understand my plans shall be used as public recon4a OVER IMO AM SQ.FT.FLOOR AREA S/SQ.FT.
[G06Z Licensed Professional SIGNS CAL
1d IhembyOWNER-BUILDER DECLARATION IAL CIRCUIT/M15C lV—
i.., owingrasen.ffimthat l am exempt from the Contractors License Law(or the
Z O.. following reason.(Section 703L5,Business and Professions Cade:Any dly or
Oz1. c TEMP.MLTFR Oft POLE INST.
� � wntywhkh rcqulresa perrNttomvtrud,ilter,knpmve,dennlLsh,orre
1 Q any atvdvre statement
that
he 6 Ilso sed pursuant to anHorsuch s t e POWER DEVICES
C 1 U file a signed statement that h t licensed pursuant to the provisions f the
OEI u, Con3ofthe License and(Chapter9(rommendngwith
nmpthemfofDivl-
i„�OS slon3ofthe Buainessand Professions Code)orthat he L+exempttherefromand SN�IMh9hC C VALUA�Oti
9a Y the basis for the alleged exemption. Any ,violation of Sedion 7Q415 q'any CJL�
4'�0
applicant fora permit subjectathe applicant to a civil penalty of not more than OUILEISSWIICHFS ES 400 air
a. five hundred dollars%- W. NEW RESID a
?�n ❑1,as owner of the property,or my employees with wages as thele sole SQ.FL SIOIIIES TYPE CONSIRl1CT10N
compensation,will do the work,and the structure 6not intended or offered for
M sale(Sec.7044,Busbessand Professions Code:The eoniradoes Liceve Law
S Q does not apply to an owner or property who Wilda or improves,thereon,and OCC.GROUP
RES.UNITS
whodoes suchworkhimseif orthmngh hisownemployees,provided that such
Impmvements stenos intended oroffered forsals.I(howevegshebuildingor T T
FE
improvement bwld withnoneyvarofcompletiogtheowner-W Bderwlll have
t odes of proving that he did not Wild or bnpowe for purpose ofule3. QTY, PLUMBING PER I E p7"OpAP
LI,as owner of the Property,am exclusively contracting with licensed p ZONE N
contractors to construct the project(Sec.7044,Business and Professions Code: PERMITISSUANCE
The
Wilds, ve Conteador's License Law does not apply to an owner of property who ALTER-DRAM&VENT-WATER(EA)
Wor improthereon, and who coned- for such pd
lojes with a
¢,6t.ra0 (e)licensed pursuant to the Coutodoe.License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LII am exempt under Sec. B&P C for this reawn
OUTSIDE
Owner Doth DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
� WORKMAN COMPENSATION DECLARATION RECER'I'a
121 hereby 1,1=that I have a mrtRlcate of consent to ulf-inwre,or a �TU�PER�P SCHOOL TAX Y_ N
o certificate ofWorkeni Compensatiml=mnaoremnifiedcopythereof(Sec, RECER'TIt
'3800,Lab C) GAS FA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Policy M
RECEIPT I
Coany he GAS EA.SYSTEM-0VFR4(FA) BUILDING DIVISION FEES
erti0ed copy b herebyted. GREASEANDUSMI,WASTE INTERCEPTOR PLANCHECK FEE
ertlRed ropy V filed withh the the city inspection division. Lfw
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID yL
COMPENSATION INSURANCE
D
(rhissedion need not becompleted tithe permit ufmonehundred dollars SEWER-SANTTARY-STORM FA.HAFT. ate Recej f#
(at I mmil,that
.) ofthe WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certify thato the person to
anymwork for which this permit Is blued,
I shoe not employ any person f any manner w as to become subject to the WATER SYSTEM/,TREATING
worlicant Compensation law.of Guramla.Date PAID
O Z Applicant
Z O NOTICETO APPLICANT.11,after makingthls CenBlateo(Exemptton,you NEN'RESIDENTIAL PLMB. SQ,FE Date Recei t#
Fshwld Mmmesubiedtotheworken'C.mpevatlonpnw ..o(the Labor TOTAL:
U) Code,you must forthwith comply with such previsions orthis permit shall be PER
i+
LU � deemed revoked.
a p CONSTRUCTION LENDING AGENCY
(LZ IhercbyafRr chat there is a covemdion lending agency for the perfomF TOTAL E
once of the warkfcar whkhthb perMlLs lowed(Sec.3097,Civ.C.ILendersName EEa znder§Address QTY. MECHANICAL PERMIT FEE L FEB
OW Icerti/ythatPhavemadthisapplivionandstatethttheaboveinformatlnbcorred.lagreemcomplywith all dlyand countyordlnancea and state lawn PERMIT ISSUANCE} N relating to building cnnstroctloa,and hereby authorize representatives of thiocit to enter upon the above-mentioned property for inspedion purposes. ALTERORADDTOMECH.(We)agree tosavqIndemnify an d keep harmless the City of Cupertno Receipt#
Wtllabillt 0pdgments,costs and expenses which may In any wayamrm ALR HANDLING UNIT CIO 10,000 CFM)
a
SUBTOTWs said Cite,igranting of this permit. AL:
AIRHANDLINGINIT(OVE10XocEM)
CONSTRUCTION TAX
."granum or APpaa.,/C nracwr Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle havardcus HFATINGUMT(TOl00,W0BT1J)
material as defined by the Cupertino Municipal Code,Chapter9.1Z and the Date ReceI t#
lie❑alt hand Safety CodNoion 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOT
Will the applicant or fuvre building occupant use equipment or devices ON FAN('INGLE RES ID) ISSUANCE DATE
eMs hones odour ane contaminants as defined by the Bay Arca Air
Qu?litY�anagement Dist°Y o7 MP OHP( 10 BT
BTU)
4havereadtheh metedabrequimmnbunder Chapter6.95ofMP(OVER 100,0W BTU) PAipkthe G71vemia I lealth&SfetyCodc,Sedi°ns25505,75533 and 25534.1Vunderstand that if the building does not arrently haveatenant,that it is myEMIALMECFI. SQ.FT.
responsiblidy to notify the occupant of the requirements which must be met 7 ���
poor to ire amaof Ce Icat or Occupancy.
�27 ani/� C11 Z
Owner or authorized agent Date
TOTAL: ISSUED BY:
OFFICE COPY