23573 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification PERNBT NO.
8ullding Acidreas: W rj1�� 23573
145)vC C?t-,
ne A V A
CITY OF CUPERTINO-BUILDING DIVISION
. ° Na LIe.N°, APPLICATION /PERMIT
grchit /Engineer 2—a BUILDING-MDCTRICAL-PLUMBING-MECHAMCAL CATEGORY CONTROL
�)_// QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: - $/aNl bi,� ELECT
PERNUTISSUANCE ❑ ❑ F-1LICENSED CONTRACTOR'S DECLARATION
I hereby affirmthat l am Beensed under provisions of Chapter 9(comncro APPU[ANC SIDENTIAL JOB DESCRUTI N
ingwith Section 7000)of Diviion3ofthe Businessand Pmfe onsCode,and my
license I,In full force and effect. PANELS
License Clam Cma 20 AM75
Date CIt.It or Y�//lam
ARCHITECTS DECLARATION
q�'+ntO ZOOC I understand my plans shag be used as public records. ER]000 AMPS SQ.Fr.FLOOR AREA $/9Q.FM
tG U Licensed Proleniavl SIGNS ELEC
OUTSI Up FEES
Z
Q OWNEReBUILDER DECLARATIONlhem ��IA /M�
k., a owing ra(0rmthatlam31.5,Bxempt usiness
om the essad profession,
Code law fort
q❑ .o Lyng reason.(Section 7 to easiness and Prolpmve a Code:Any ci
F's ° ntywhich mqu rod pemd towroty a ter,mpmvq dennlbh,o par TSP.M OR POLE Sr.
J anystructure prlorm its Issuance,also requireathe applicantfor so rmlt to PO
Q 3 fd G file a signed statement that he Is licensed pursuant to the proves of the
O u. EVICES
Contractor's License Law(Chapter 9(commencing with Section 7000 Dlvi-
f„ O ,Ion 3ofthe Buslnvs and Promast..Code)or that he is exempt therefrom d S NC L CTRIC VALUATION
Qy.'g the basis for the alleged exemption. Any violation of Section 7fp1.5 by an
g E3<5
applicant fora permit subjects the applicant to a civil peruityofnot more than HES- EPS
five hundred dollars($.500). NE
^�^ I,as owner of the my employees B �'�' TITECONSTRUCUON
I 77 compensation,will do the work and the structure 6 not'Intended or offered for
ALE TR SrpRIES
S N O sale(Sec.7064,Business and I'mfemions Code:The Contractors License Law�j 53 dare net apply to an owner of property who builds or improves thereon,and OCC.GROUP RFS.UNITS
who does such work himself orahrough his own employees,provided that such
Improvements are Act intended oroffered for sale.IL however thebuilding or TOTAL:
improvement u sold within oneyearofcompletlon,the owner-bu Ilderwill have
the raen of proving that he did not build or Improve for purpose°f sale). QTy. PLUMBING PERMIT FEE ETppDZONE APN
Lj L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7014,Business and professions Code:
The Contractor's License Law does net apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon, and who contracts for such pWiecta with a
IN
licensed pursuant to the Contractor's License Law. gpr�g plpW pgOTECT.DEVICE FEE SUMMARY
I I am exempt under Sec. B &P C for this means
. Owner Date DRAINS FLOOR ROOF,AREA,COND. SAMTARY Y N_
WORKMAN COMPENSATION DECLARATIONWTR"
RECEIPT�$
❑I hereby affirm that I have a cortifivfe of consent to self-Insure,or aFR�P SCHOOL TAX Y N
certificate of Workers'Compensation Ins.more ora certified copy thereof tSecREGEPT M
M00,lab C.) TEM-1 INCAOUTLETS PARK FEE Y N
Policy p RECEIPT N
Com any STEM.OVER 4(EA) BUILDINGDI VISION FEES
copy Is hereby furnished.
❑Certified copy 6 filed with the city inspection division. DUSIRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS P PAID
COMPENSATION INSURANCE
frhmaectmnneed not becompietea lflheperndt fsforone hundred dollarsITARY-STORM EA.200FI'. Date Recei t#
(510(Borfesw) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
Icertlfy that In the performance o([he work forwNch this penNtbed
lssu ,
I shall not employ any person In any manner an as to become subject to the
Workers Compensation laws of California.Date WATER SYSTEM/TRGTING PAID
O Applicant
Z 0 NOTICETOAIP ICAM:If,aRermakingthb Cenificateof Eaemptlon,you NEW RESIDENTIAL PLMB. SQ,Fr. Date Recel t#
should bee comsubject to the Workers'Compensat Ion provisions of the Labor
N Code,you must forthwith comply with such provisiore mi
orthis pert shall he TOTAL:
W > deemed revoked. - BUILDING FEE
d p CONSTRUCTION LENDING AGENCY SEISMIC FEE
aIs Ised097
Ihercbyaffinnthatthere Isacovtmctlonlandingagenryforthepedorrm 0 nce of the work which this permit su (Sec.3 ,Civ.C.) L ELECTRIC FEE
O Icnaer'e Name PLUMBING FEE
ly 0 <naeragthatlh QTv. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertifythatl havervathisapplicitynand dcuntthatyordi ancesed at,aaw,
1 iscomect agrcet°c°mply with allcityaed county ordinances and atatelaws PERMIT ISSUANCE FEES PAID:
r W mlaUnglobuilding coves"Ion,and herebyauthodmrepnesentativesolthis
f. Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
V — (We)agree to neve,indemnify an d keep harmless the City of Cupertino - Date Receipt#
agalmliWbUilie9 judgme sand expcme3whichmayin anywayacove AIRHANDLINGUNH(TOIo,o00CIM)
against CI mro enre ooh graining°(Nle permit SUBTOTAL:
—5D AIR HANDLING UNIT(OVER 10,000CEM) CONSTRUCTION TAX
nsrorenr Appli8useContrnct.r Date f EXHAUST I'IOOD(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)
materials,defined by the Cupertino Municipal Code,Chapter 9.12,and the Date R
Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,"BTU)
❑ nee, I`I Nn T L:
Willtheappliont or tare building occupant use equipment or devices VENITLATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
• Quality Management District?No BOILER-COMP PFEPOR 100,0(0 BTU) SEP : 8 /�
- Yee FF��No 199`}
4havereaa tealth&he h afetyC de,Se reons 25Sntsunder Chapter.1 of BOILER-COMP(OVE2100,OOO BTU)
the CallfornW]iealth&SafetyCode,Sections 75505,25533 and 755M.I '
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH, SQ.FI' Cil1 UY IaUT'CTIIIIVIJ
nspomibllity to notify the occupant of the requirements which must be met
Odor to issuance of a Certificate of Occvpanry.
Owner or authodud agent Date
TOTAL: ISSUED 8Y:
OFFICE COPY