23850 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: 23850
t 1 3 D Slcsl Porcl Or
C�^�e�rs ante: one: App ION SUBMIl IAL UA lh
L�py( n i k P ice41 CITY OF CUPERTINO-BUILDING DIVISION
Cont"°msNamni Lie.No: APPLICATION / PERMIT /
3 Sli BUfLDINC—nECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL If
text/Fagmeer. Lic.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: CZA Cc_ ( PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commse APPLIANCES RESIDENTIAL J,OB DESCRE'ITON
Ingwith SecUon700B)ol Dlvlslon3ofthe Buslnessand PmfnsionsCode,and my
license is in full force and affM. q PANELS
Limnsc Cla.C:_-2_7 Licp .390 3S/
DataContractor —IM IQ 2DOAbMS
ARCHITECTS DECLARATION 201-1000 AMPS
�Z I understand my phis shall W used as public records. OVERIOOOAMPS SQ.I`MFLOORARIA $/SQ,FT.
mdo Licensed Professlovl SIGNSELEC MCAL �,� ® I LI
6 OWI am exempt LDER
DECLARATION a 00A
7pIhyrebyalRrmthatlamexemptfromthe Contractors License law fortheSPECIAL CIRCUIT/MISC foll �p METER OR POLE INST.KmG =ntywhtchre"tmapermittomrstrunalter,lmpmvgdemolbh,orrepair �� anystmc mpdortoibLu ance,aLomquimstheappliantforsuchpermitto 1'OWF.R DEVICES
O DATE—
file a signed statement that W b licensed pursuant to the pmvislons of the
YOB Contractor's License Law(Chapter 9(commencing with Section 7000)of Devi- SWIMMING POOL I7,EC'I'FtIC
sion3 ofthe Business and Profcaslonu Code)orthat heat exempt therefromand VALVA J2]
5 the basis for the alleged exemption. Any violation of Section 7031.5 by any /)D� w
OS(� applicant for a permit subjects the applicant to a civil penalty of nM morethan OUTLETSSWI7CHFSFTXTURFS lqL
live hundred dollars($M. NEW RESIDENTIAL ELECTR
❑I,as owner of the property,or my employees with wages as their aide SQ'F. STORIES TYPE CONSTRUCTION
K < compensation,wlllciothe work andthe structure is not Intended or offeredfor
❑ sale&c.7044,Business and Professions Code:The Cormictoes Liceme law
$ does not apply to an owner of property who builds or Improves thereon,and
who docssuch work himself or through his own employees,provided that such CCC.GROUPRFSUNT
improvementsarcnot intendedoro(fend (orsale.If,howeverthebuildingor TOTAL:
improvement beeld withlnomyearofcompletiomtheowner-bullderwgI have
th�rdenofprovingthat he did notbu0dorimproveforpurposeofsale.). QTY. PLUMBING PERMIT FEE 1•U)ODTONE XpN
I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
couracton to construct the project(Sec.7016,Business and Professions Code:
The Contractor's License Law does rad apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon, and who contracts for such piojenni with a
ott[actor(s)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LII am exempt under Sec. B&P C for thb means
•
OUTSIDE FEI'S___
Owner DEANS.FLOOR,ROOF,AREA,GOND. SANITARY Y N DEANS.
WORKMAN COMPENSATION DECLARATION RECEIPT 0
t hereby affirm that I have a cectiBatc of consent m self-Insure,ora F0(I1IRES PER TRAP SCIi00L TAX Y N
rtificne of Worken'Compematim Imuran or a certified mpythereof(Sec. RECEIPT M
3800,Lab C.) GAS EA.SYSI'FM-I INCAOUTLET5 PARK FEE Y_ N_
policy � /�9'(7 L.—fl. RECEE'Tk
R
t GAS EASYSTEM-0VFR4(FA)
nUedmpybhembytumbhed. BUILDING
DIVISION FGES
edified copy b filed with the city inspection division. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPHON FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Thtsection need not beemnplated lfthe permit bforonehundred dollars SEINER-SANITARY-STORM EA.200FT. Date RCCCI t#
($103)or lyse.) in WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I ll mot that employ
an p Pa..in say
work.g;t-becls ome it
to he' _
I shall not employ my person in any manner m as to Wcome subject to the WATEtSYSTEM/TREATING
WorlicApplican Compewtlon laws of Califomt.Data PAID
Z NOTICE NEW RESIDENTIAL PLMB. SQ,ET. Date Revel t#
Z O NOTICEco NTL),&tot e aBeaerVC.g thisCertBkate of Exemption,you
F — should become subject to the Worken'Compvsatlon provisions of the Labor TOTAL'
WN Code,you must fort hwith comply with such provisions or this permit shall be
> deemed revoked. TBUILDINQ a,CONSTRUCTION LENDING AGENCY I herebyalfirmthat there baroratmctlon lendingagency forthe performZ ance of the work for which this permitb bamd(Sec.3097,Civ.C.) TOTAL: EILS Landr,sAddreaa QTY. MECHANICAL PERMIT FEE FEE
OWIcertify that l have read that application and state that the above Information1 b correct l agree to comply with all city arad county ordinanms and state laws PERMIT ISSUANCE
} N relating to building rorotructlon,and hereby authorize representative o![his
f- Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
(We)agree to save,Indemnify an d keep harmiess the City of Cupertino Date Receipt#
against liabilities,judgment,rostaant]ex erases whlchmaylnanywayaccrue AIR HANDLING UNIT(To 10,000 CFM) SUBTOTAL:
1 Ity in ronseyu7; of the anon;of this permit
J =Z. i I�_? AIR HANDLING UNIT(OVER 1g0D0CFM) CONSTRUCTION TAX
Sigfia of Applinn�cmr Date— EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazaMous HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 933 and theWNEWRESIDEN-nALMD04,
Date Recei t#
Flmlth and Safety Code Section 8532(x)7 UNIT(OVER]00,003 BTU) TOTA
Yes M No
Will the applicant orfuturc building occupant use equipment or devices VENTILATION FAN(SIKGLE RESID) ISSUANCE DATE
which emit havardous air contaminants as defined by t ed Bay Area AirBs, pp
• Quality Management District? PFR'OR 100,000 BTU) It— W 8
4 Yes d No
have read thehuar us materials rcqulrcments under Chapter 6.95 of BOILER-COMP BTU)
the Glifomb Health&Safety Code,Sect lona 25505,25533 and 25534.1UIQ .a
understand that it the building docs not mrrently have atenanL that ltbmyIAL ME CH. SQFf. {l 1 �A(I�
impossibility to notify the occupant of the requirements which must be met99pror to issuance of a Certificate of Occupancy. Cil r UI' Cured
I It VV
Ownerorauthod dagent Date
TOTAL: ISSUED BY.—
OFFICE COPY