23577 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES = USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Rdllding Address:
cis s� ate, - 23577
wners ams: CCAPPLICAT
QT— d CITY OF CUPERTINO-BUILDING DIVISION
red
etors"arae, Lie,No: APPLICATION / PERMIT
BURDING-ELECTRICALPLUMBING-MECFIAMCAL CATEGORY CONTROL#
Architect/Engineer. LIB No:
QTY ELECTRIC PERMIT . FEE BUILDING PERMIT INFO
Address PERMIT ISSUANCE =;;;e 1:1 ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby dfironfloul am licensed under provisions.(Chapter9(mmmenc APPLIANCES-RESIDENTIAL DFSCRB'HON
ingwlth Seadon7000)of DiNsim3ofthe BuslncaaandlhofeWonsCodgand my
11...is In full force and effect. PANELS mfr S'KV a�■� 1 s
License Class LM.#
Date Contractor
1 ARCHITECTS DECLARATION 201-1000AMPS
�ppFuu 0 CO I understand my plane shag be used as public records. OVER IOW AMT'S - SQ.ET.FLOOR AREA
Fi U Licensed Praksalorui SICNSELECTRICAL
< OWNER-BUILDER DECLARATION s SPECIALCIRCU1T/MLSC
�LL�`T
Z ?, I hereby afRnn that lam exempt from the Contractor.Liana Law for the
qqqqqq (.Mowing reason.(Section 70715,Business and Professlons Code:An cityr
F k' cote ey which requires a permit to andmet,alter,Impowedemallsh,err reair TEMP,MECER OR POLE INSf.
nytlmcture prior to Its Issuance,also requires the applicant for such permit to
file a signed statement that he Is licensed punuant to the Provisions of the POWER DEVICES
3u0 Contractors License Law(Chepler9(mmmencing wfth Section 7000)of Divi. SWIMMING POOL ELECTRIC
coni ofthe Budersda tel PrafemimuCode)orthat he is exempt therefromand VALUATION
yd S the bases for the alleged exemption. Any Violation of Sectlon 70315 by any
G
applicant for a permit subjects the applicant to a elvll penalty of not more t hen OUTLETSSWITCFIESH%TURES
five Jrdmd tlollen($500). NEW RESIDENTIALELECTR FT.
QQQ �n as owner of the property,or my employees with wages as their sole `"Q STORIES TYPE CONSTRUCTION
mpensaHon,wllldothe work and thes"cume Isnot Intended or offered for
e(Sec 70K Bwineu and PrerEod ms Code:The Contractors License law
$ does not apply to an owner of property who build.or improves thereon and OCC.GROUP RES.UNITS
who doessuchwurkhlmeero
lf.rthugh hisownemployees,provided thatsuch
Improvementeam notlntended oro(fered forsale.If,howevepthebullding or T
improvementls.oldwlthlnoneyearofcomplellogthev ner-bullderwlll h1ve
fitc*,den of proving that he did not build or improve for purpose ofvb.). QTy- PLUMBING PERMIT FEE pT-OODZONe APN '
LJ L as owner of the pmperty,am exclusively contracting with licensed PERMIT ISSUANCE
to eurutmet the project(Sec.703,Business and Pro(essl.ru Code:
The Contractor'.License law does not apply to an owner of property who ALTER-DRAIN&VENT WATER(EA)
builds or improves thereon,and who contracts for such pro)ects with e
cgBjxdar(s)licensed pendent to the Contractors Llan.Law. BACK FLOW PROTECT DEVICE FEE SUMMARY
LJ I am exempt under Sac B k P C for this recon
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y— N_-
ner Date RECEIPT#
WOR KMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a cerHat
Oe of consent to self-InureFIXTURES-PERTRAP, SCHOOL TAX Y N_RECEIPT N
certNatc o(Worken'Compensatlonlreurance ora artlflcd ropythensof t5ec. GAS EA. WC.40[TR.EfS
3600,lab CJ .PARK FEE Y— N
Poilry M. GAS EA.SYSTEM-OVER4(EA) RECEIPT N
Com any BUILDING DIVISION FF ES
�Certifled copy is hereby with
the city GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�CcrtOied copy V filed with the city impaction division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.20OFT. Date Rewi t#
(0)m lection need rad be completed lithe permit tr forone hundred dollen
(ft ss.)
I.Aifythat lnthe perfoWATER HEATER W/VENT/ERECTR ENERGY FEE Y N—
I
olthe waklorwMch lhls pemNtb Wiled, —
I shall not employ any person In any runner u as to become ubjeet to the WATER SYSTE M/TREATING
r:Compensation laws of California.Date PAID
worke
O.Z Applicant NEW RESIDENTIAL PLMS._SQFT. Date Remi t#
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should become sub)ea to the Workers'Corepcvatlon provHlotu of the Labor TOTAL:
m Code,you mast forthwith comply with such provisions or this permit Asti be UI E
`J deemed revoked.
W
G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a mncutlion lendingagency far the perform ELECTRIC FEE
D O arca of the work(.,which this permit te Issued(See.3097,Civ,G TOTAL:
(,) larders Name - PLUMBING FEE
LL F Lerder.Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I cerHfythat l have madthbapphatlonated state thattheabove lnformatlon
6 Is correct.I agree to complywlth all cityand county ordinances and state laws PERMITISSUANCE FEESPAID:
} relating to building mmtuctlon,and hereby authorize representatives ofthln
• �.. city to enterupon the abovnmentbned property for Inspection purposes. ALTERORADD7OMECH. Date ReCel t#
E5I (We)agree to save,Inde an d keep herr the City of Cupertino P
against liabilities,judgmen sarW..Exames Ich may Ir anymy.ccma AIR HANDLING UNIT(TO 10,000CEM) SUBTOTAL:
agaimtsald Ci con nc cefthegrsntln this permit.
AIR HANDLING UNIT(OVER IO,000 CFM) CONSTRUCTIONTAX
Igmr.reo Pliant/ our or 'Date EXHAUST HOOD N/DUCT) CONSTRUCTION TAX PAID:
HAZAIIDOLN MATERIALS DISCLOSURE
Will the applicant or future building occupant atom or handle hazardous HEATINGUMT(TO100,0000TU) Date Reeei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
Health and SafetyC.dr Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL,
❑Y. r]No
Will the applicant or town building oavpant use equipment or devices VFNITLATION FAN(SINGLE RESID) ISSUANCE DATE
which emithazardous air contaminants as defined by the Bay Arca Air
W Illy Macover
District? BORER-COMPOFE'OR100,0000TU)
('r 'yes . �1 No
4luve read the hazar�. m
us materials mquireerts under Che pter 6.95 of BORER COMP(OVER 100,000 BTU) PAID
the Cali(omta Health k SaMin Code, of co rre 25505,25S33.t and 75534.I
undenand thatn of thecngdoes of
errcuireme is which that it met NEW RESIDENTIAL MECH. SQ.IT APR LE9 �f
responsibility to notify the.sups rat of the requirements which must be met ]s79
prior to Issuance of a Certificate of Occupancy. Ch 19
Owneror authorized agent Date ISSUEDBY: a (/
TOTAL:
OFFICE COPY