23687 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Balloting Address:
23687
vers seas: one: A A
�nSG�Q YC. Z53-
51 CITY OF CUPERTINO-BUILDING DIVISION
• Comracto'sName: Ic.Na APPLICATION I PERMIT J G
D
r)-p—S sonI 9'035 BUILDINGELFjCTRICAI PLUMBING-MMHANICAL CATEGORY CONTROL tl
Arctuten/Englneet.. Lle.No:
' I QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:�3 &Jb00(C(r U J PERMTISSUANCE I® ❑ 1:1 ElLICENSED CONTRACTOR'S DECLARATION Ir
I hereby iffirenthatI am licensed under provi,lontuf Chapter9(rommmc APPUANCESRESIDENTTAL jOBDESCRUMON
ingwilh Section7000)of Dlvlsion3ofthe Businemand Peafessiom Code,and my
license is In full d effect. '2 0 3 S PANELS
LlcenseC r Llc.tl . ��
Dat Contactor
ARCHITECT CLARATION 201-1000 AMPS
NO ZOC I understand my phro shall be used as public records OVER 7000 A.MI'S �.FT.FLOOR AREA S/SQ.FT.
l�E Limosed Pmfesslonal SIGNS ELECTRICAL
6 OWNER-BUILDER DECLARATION SPECIAL CIItCN7/MLSC
Iherebyaffirm that lam exempt learn the Contractors License Law fm the
following reason.(Section 70315,Business and Professions Code:Any city or
KMI"8 county which requiresa permit tocotruc;after,Improvm
Impactive,deolbh,orrepair TEMP.METER OR POLE INST.
�S'� any steacture prior to its Issuance,also requires the applicant fm such permit to
file a signed statement that he b licensed pursuant to the provisions of the TOWER DEVICES '
Contractor's License,Law(Chapter 9(mmmencingwith Section7000)ofDivi- SWAMINGPOOL ELECT C
H O ston3ofthe Buslnessand I'messimu Cod.)orthat helsexempttherefromand VALUATION
Sn the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora permit subjects the applicant to a civil penalty of not more than OUTLETSSW[TCFIFS
E Q five hundred dollar(Aq. NEW RESIDENTIAL ELECTR SQSr
j 1,as owner of the property,or my employees with wage as Chair sole 1 TYPE CONSTRUCTION
G compensation,willdothework,andthestrurtureianotlntended or offered for A-��
5�,jO sale(Sec.7044,Business and Pea(emloria Cade:The Contractofa Lt..Law
E�R does not apply to an owner of property who Wilds or improves thereon and
who does such work himself or through hisown employees,provided that such OCC.GRO RES.UNITS
Improvements are not Intended or offered for sale.I(however,the building m TOTAL:
Improvement Is sold withinoneyearofcompletion,the owner-builder will have
t Iden of proving that he did nm Wild or improve for purpose of a ale.). QTY, PLUMBING PERMIT FEE APN
Lj L as owner of the property,am exclusively contracting with Ilmosed FLOOD ZONE
PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractor's Licerue Law does net apply to an owner of property who ALTER-DRAIN k VENT.WA
ti'JJ
Wilds or Improve,therm
s,and who contracts for such ptojects with a
- t_f^ctaRs)bcensed pursuant to the Contractote License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
IJ 1 am exempt under Sec B k P C for this reason
Owner DateDRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
• WORKMAN COMPENSATION DECLARATION RECEIPT p
❑f hereby affirm that I have a certificate of consent to self-Insure,or a FIXTURFS PER TRAP SCHOOL TAX Y N
certi(Icateo(Worken'Competuation lnsunnceara certllled copy thereof l5ec. RECEMT N
380'Lab C.) //yy , / GAS PA.SYSTEM-1 INC.4 OUTLETS PARK FEE Y N
Policy Til S—i C.P 4 RECEIIaT'p
C[gCry 1� �` GAS EA.SYSTEM-OVER 4(FA)
BUILDING OIVISIONFEES
Certlficd copy b hereby famished.
Q e ffied copy is filed with the city Inspection division. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(rhlssectlon need not becomplated ifthepermit isketcon hundeaddollaes SEWER-SANITARY-STORM EA.200Ff. Date Remi (#
(5100)itifyt.) WATER ENERGY FEE Y N_
(certify that In the per(ormanceof the work forwhlch this permit is Lwaued, HEATER W/VENT/ELECIR _
I shall not employ any person In any manner so as to become subject to the
Worker Compensation Laws of CaBfomis. Date—
0
SYSTEM/TREATING
O Z Applicant PAID
_Z 0 NOTICETO APPLICANT.If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.F(. Date Recei t#
~
should become subject to the Workeri Compemuatlon provisions of the Labor N Code,you most forthwith comply with such provLslore orchis permit shall be TOTAL:
W > deemed revoked. BUILDING ELE •00
0 O CONSTRUCTION LENDING AGENCY
SEISMIC FEE
= Z Ihereby affirm that there is a mmwction lending agency for the perform ELECTRIC FEE a
O ance of the work for which this permit is handed(Eke.3097,Civ.C.) TOTAL:
U dere Name PLUMBING FEE
LL F (.enders Addmss QTY. MECHANICAL PERMIT FEE
O w Icemfythat I have read this application and state that the above information MECHANICAL FEE
1 6rorrcct.I agree to comply with all dtyand county ordinances and pate laws PERMIT ISSUANCE FEE$PAID:
} W relating to building construction,and herebyauthorize erpresentativesofthis
F Z city to enter upon the abovnmentioned property for lepttllon purpose. ALITRORADDTOMECH.
(We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
against liabilities,Judgments,costa ex rues which may in anywayacvue AIR HANDLING UNIT(TO 10,000 GEM) SUBTOTAL:
against said in of arcing of this it.
AlR HANDLING UNTT(DVER10,000CFM) CONSTRUCTION TAX
Signature of Ap (cant/cont, 0 1)a HAUST HOOD(W/DIICTI CONSTRUCTION TAX PAID:
HALkRDOUS TERIALSD CLOSURE
Willtheapplicant or future building occupant store or handle hazardous IiFATING UNIT ITO 101,000 BTU)
mterialas cieRned by the Cupertino Munidpa l Code,Chapter 9.1 2,and the _ Date Reeei t#
Health and Safety Code Section 25532(a)r HEA TING UNIT(Om 100,000 BTU) TOTAL: � � O
0 Y. M No •
Wilitheapplicant or future building occupantment
useequlpardevice, VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emita
harch us atsir contaremainas defined by the Bay Area Air
• Qu lity Management Distdct7 BOILER-COMP OHPOR 100,00 BTI()
4Yea ❑❑No
have read the hazardoa materlals requirements under Chapter 6.95 of BOILER-COMP(OVEB100,000Btt3) T p B
the Cillfomu &
Health Code,Sectlom 25505,25533 and 25534.] 1!' P4
understand that lithe Wilding does not currently have a tenant.that It Is my NEW RESIDENTIAL MECH. SQ.F( �.'/
ramlbB
poity to notify the occupant of the requirements which of must be met Ia 15 19 '`
PH.,to ksuanm a Certificate of o.pancy. PRAY
Owner or authorized agent Date tI,
TOTAL: ISSUEDB` s I - IIYV
OFFICE COPY