23917 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES USE BALL POINT PEN ONLY
Building Pro'ed Identification PERMIT NO.
Building Address:
23917
Fane:
A A
r7�i CITY OF CUPERTINO-BUILDING DIVISION
ContranorsMS � Lk.No: APPLICATION I PERMIT
BUILDING-ELECTiUCAL-PLUMBINC MECHAMCAL CATEGORY CONTROL I
Architect/ grocer. Lie.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address:
PERMITISSIiANCE 1:1 ❑ ❑
LICENSED CONTRAROr pr DECLARATION
I lath Sb iffirmlhatlam herMonuni 3ofthe under nmand Pre Chapter9de,and c APPLIANCES-RESIDENTIAL JOB DESCRIPTION
It...I Section 7000)o(d effimn3ofthe Buslnessand ProlesslonsCode,and my �
license h in full to d effect PANELS
License Chu Lic M 4Y��1♦(�
Contractor
ARCHITBCI'S DECRATION 211-1000 AMS Com' n
lQ+�rcOzp TundentandmyphmshaBbeuud publlcmm s. OVERIODO AMPS .FI. s`JD A S/SQ.FT.
E c(/ Licensed Professional SIGNSELECTRICAL a
�6
f' a OW1,MR-BUILDER DECLARATION
IhercbyaOm SPECIALCIRCUT/MISC
p O following moor.(Section 7031.5,mdtbud and Pro prove, Code:Any dep it 1
K (
county which requlrcsa permit toconstwgilter,improve,demolbh,orrepalr TEMP.MEM OR POLE INST. DAT
7 aoystructure pdortolb lawance,also requlresthe applicant!couch permit to
3 file a signed statement that he In licensed pursuant to the provisions of the POWER DEVICES
Contractor's License Taw(Chapter 9(commencing with Section 7000)of Divi. SWIMMING POOL ELECTRIC
r,,0 eIon3 ofthe Businessand Professions Code)orthat he b exempttherefromand VALUATION
< the basis for the alleged exemption. Any violation of Section 7allS by any OUTLETSSWIICHESFIXTURES
applicant fora permit subjects the applkant to a dull penalty a rat more than
c.gg five hundred dollars($500).
p 7 ❑I,as owner of the property,or my employees with wage as their sole NEW RESIDENTIAL ELECTR SQJT STORIES TYPE CONSTRUCTION
a compensation,will do the work,and the structure b not intended or offered for
p soin&c.7044,Busheas and Profeuloes Code:The Contractor's License law
PyF does not apply to an owner of property who Wilda or improves thereon,and
eC.• who doessuchworkhmariforthrough hisownemployees,provided thatwch OCC GROl1I' RFS.UMCS
improvements arena intended oroffered forsale.IL however,thebullding or TOTAL:
improvement hsold withinoneyearofcompl&IoNthe awner-buRderwilluve
the burden of proving that hedidnot Wndorimproveforpurposeo(sake.). QTy, PLUMBING PERMIT
ElL as owner of the property,am exclusively contracting with licensedE FLOOD ZANB MN
contractors to construct the project(Sec 70K Bu loess and Professbm Code: PERMIT ISSUANCE
The Contractile.License Law don not apply to an owner of property who ALTERD
W116 or improves thereon,end who contract. fa - RAW k VFNT-
such p(ojects with a WATT(EA)
cgIllpictor(a)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B k P C for this reason
FFrS
Owner Date DRAINS FLOOR,ROOF,AREA,GOND. SANITARY Y_ NOUTSI �WORKMAN COMPENSATION DECLARATION RECEIPT
Ell hereby affirm that I have a certBfate of consent to self-Inwre,ec a FaNRF_S PER TRAP SCHOOL TAX Y N
certlRate of Workers CompensaBonInsurance or acertified copythereof(Sec. RECEB'T It
S
3800,Lab C.) GAEA.SYSTEM-1 INCA 0VTLETS PARK FEE Y N_
I'oliryp_ d /�'
Com any C 7 GAS EA.SYSTEM-OVER 4(EA) RECEIPT
BUILDING DIVISION FEES
❑pCertkfied ropy herebytumecityheo. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
r Certified copy b filed with the city inspection division.
CERTIFICATE OF EXMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(this section ne dnrt be completed if the permit Ls(Drone hundred dollars SEWER-SANITARY-STOORM EA.2pOFT.
conifyDate RCCYi [#
(510 ss.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N_
I certifythal in the performance of thework forwNch this permit Is(awed,
I sha0 not employ any person In any manner at as m become wbject to the
O Applicant
Worl�n'Compenutlon Lawn of California. Date WATER SYSTEM/TRFAliNC
rp PAID
Z 0 NOUCETOAPPLICAM:IL after makkngthb CerlBicateof Exemptlon,you NEW RESIDENTIAL PLNB.__SQFr. Date Recei t#
should become subject to the Workers Compe cation provbiom of the LaW r TOTAL:
W~ 0 Code,you must forthwith comply with such provisions orthts permit shall W
j deemed revoked. BUILDING FE
CL F3 CONSTRUCTION LENDINGAGENCY SEISMIC FEE
= Z I hereby affirm that there h a construction lending agency for the perform,
O arm of the work for which this permit b Lowed lSec.3097,Clv.C.) TOTAL: ELECTRIC FEE
U kcuder'e Nacre PLUMBING FEE
LL F Lendee.Addreas QTY. MECHANICAL PERMIT FEE
O w IceititythatlhaveradtMsappliationandmatethatthuboveinformation MECHANICAL FEE
b comect.I agree to comply with all city and county ordknancesand state laws PERMIT ISSUANCE FEES PAID:
T Wrekating(obulkdirgconstrudion,and herebyauthorecrepresentatkvesr(this
H Z city to enter upon the above.mentioned property for Inspection purpose.. ALTERORADDTOMECH.
— (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
against habNtles,judgment.,mstsand expenses which may in anywayac c AIR HANDLING UNIT(t010,M0 CFM)
against said ryce
in conssenof the granting a this permit. SUBTOTAL:
(:.,-),9 AIR HANDLING UNIT(OVER IO,000CFM) CONSTRUCTION TAX
gram — p omractor Date` EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willthe applicant orfuture building occupant stare or handle havrdous HEATING UNIT(TO 100,000 BITH
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the _ Date Recei t#
Health and Safr Code Section 2SS32(a)1 HEATING UNIT(OVER IOD,000 BTU) TO R
F-1Yes .
Will the applicant or rebuilding..part..equipment or devices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which emit hs.rdous air mmlm
rlanb fin
as deed by the Bay Area Air
Quality Management District? BOILER-COMP OIN OR 100,0())BTU) I}g Al
4Yes o r
have read the herr ous maledals requirements under Chapter 6.95 of BOILER-COMP(OVER100,000 BTU)
the California Health&rdy Code,Sedkom 25505,25533 and 25534.1 3 0 1992
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT 971m
raponeibility to notify the occupant of the requirements which must be met sJN /////�����saaaj����
4tmu
as nifiateofOccupancy. UfG %It1P
l�F �I
{ied agent Date
IOTA L: ISSUED BY:
OFFICE COPY