23623APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
PERMIT NO.
Building Address:
23623
N. .maa Phone:
CITY OP CUPERTINO-BUM DIN DIVISION
APPLICA/ PE IT
BUILDINC-ELECTRICA UMBINC-MMCAL
APpuCATr57MMMTrFXI7 p
L
is Name: �.+ No:
i -/
Architect/Engineer Ln. No:
CATEGORY
C M
QTY ELE TRI
PER FEE
BUILDING PERMIT INFO
Address:
PE3MTI AN
LICENSED CONTRACTOR'S DECLARATION
IMhSydio lrm0).(Dt §m3ofheBuklichrosed under provisionsndPrfChapter9(r,and e-
inonse ISeRlana0...aDivi 3o(the Buslwsand Professions Crde,and my
Ikxnse is In rce and e
APPI-1 NC REBIDE L
JOB DESCRIPTION
License m Ice
Data C ct
M
HI ECLARATIONte
enland m aha sed n public records
L chnx roles. ora
'1
OV
FT.FLOORAREA
aPees
$/SQ. FT.
�
SIC 5
CAL
L IRC
T/ r, pj
OWN] - UILDER DECLARATION
(following alarm lMtla eaemplfromthe Contractors License Law fort he
I at 11 1
TE(p MEI'FR ORPO INST. �y+�
,
cmnt which quimsapern. (Section Ito Business and Professions
e=Ush.y cttyor
countywbthe requires.isma
kh,orrep�rtto
ct aL requi stheaproantfor
anyatructurc statemep�artont
he 13 tLsore d par heapp thepro inions of t e
pursuant it 1Se provisions of the
Cfile a signed statement that he t. r9 (commencing
Contractor's usi License Law (Chapter 9 (rommcnctng with Semon hemi of Divi-
exempt therefrom and
ppWgB DEVICES 1 ✓ � 1 V B
-
-
.F
SWIMMING L dE � T
VALUATION
the basis fo the alleged exemption. Any violation
the basis for the alleged exemption. Any violation of nettSection not m by an
of
appBcanHora perrNt subjects the applicant to civil penalty of not mon than
UTLETSSW) SFTXTURES
NEW RESIDENTIAL ELECTR SQ.FT.
fivehuncir dolWs(5500).
❑I'as owner of the property, or my employees with wages as t Mir sok
SfOHIFS
TYPE CONSTRUCTION
compensation, will do the work and the structure R not Intended or offered for
.to (Sec. 70K Business end Professkm Code: The Contractors License Law
does not apply to an owner of property who builds or Improves lMrwn,and
who dre.such work himself orthrough hisown employees, provided that such
OCC.GROf1P
RES. UNITS
Improvements are not intended oroffered forsele. If, however,thebullding or
Improvement hisoldwithinoneyearofcompletion,the owner-builderwlil have
-
tl,C.Iiurdenof proving that he did nm purpose o
build or Improve for ofuk).
LJ L as owner tr the Property, (m exclusively Businessand ro with e; Code.
contractors mnLWct the project (Sec. appy Business and Pf Cade:
QTY, PLUMBING PET
RMIFEE
—FLOOD
PERMIT ISSUANCE
7ANE
APN
ct
The Contractor's Imp b License law don not apply to an owner of property who
proper
builds or improves thereon, and who contracts for such projects with a
m ctor(sexempt under Smrothe Conlnctor's Lichnse Law.
LJ I am exempt under Sec B & P C for ml. reasonOUTSIDE
ALM -DRAIN k VENT- WATER (EA)
FEE SUMMARY
gAIX FLOW PROTECT. DEVICE
FEES
DRAINS FLOOR ROOF, AREA, COND.
FD(TURES PER TRAP
SANITARY Y N
plpp p
Owner Data
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have to of consent to tnaun, ora
certificate of Workers CompersaRon imus lrsurance ora cedlfkd copypy thereof(Sec.
3500, Lab C.)
SCHOOL TAX Y_ N_
RECEIPT N
CAS�EA. SYSTEM -I INCA OUTLETS
PARK FEE Y N
PolCom Y
RING
GAS EA. SYSTEM -OVER 4IRA)
Co..
BUILDING DIVISION ISION FEES
DIV
IOed copy is herebydwith the city
Cnrtifted ropy V (fled with the city inspection division.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
{..�
���
GREASRTRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ThissemOn need not M complutM tithe permit l9 for ane hundred dollars
PAID 1
Date RC t ��
SEWER -SANITARY STORM EA 2MFT
WATER HEATMW/VENT/ELCCTR
ENERGY FEE Y N
PAID
Date ReceI t#
($1 mAify(h permit Is ba the,
I cecoy Ihat Mt he person
unceofthework fors to become
I shall not employ any person In any manner w n to become subject to the
Applicant Compensation Maws of California. Date
Applicant
NOTICEca esubjeAPPLICAM:eaftermakingthisustlanlproiscate of Ens of the ,you
should Mm=e subject to the Workers' wt provisions of the Labor
WATER SYSTW/TREATING
NEW RESiMMAL PLMB. SQ.FT,
TOTAL'
Code, you mwstfort hwith comply with such provblors orchis permit shall be
such i io
deemed revoked.
IL
CONSTRUCTION LENDING AGENCY
Ihembyaffirm that there k a construction lending agency for the perform-
..ca of the work for which this permit k Wued (Sec. 3097, Clv. C.)
O r
��
-
QTY.. MECHANICAL PERMIT .'FEE
7CF
Le.aeraName
Lender's Addrow
Imdifythatl Mve readthisapp11 1 cul state lhatthe above Information
bcomwt. Iagraetoco=ply with. and county ordinancesandreatelawa
FEE'
PERMIT ISSUANCE ��
relating tobullding troctlo Mm yauthodurepresentativesofthkcity
to enteru a bovc n .ed property for Inspection purpose.
(We) a o e and p harmlem the Cly Cupert no
the
AL TERORADDTOMECH.
Receipt#
SUBTOTAL•
against) tU , dg ts atsan rase, which ways
.g.las ity in ch each of ..ting of this pe 1
L
AIR FIANDLINC UNIT (TO 10,000 CFM)
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
-gratum. FEEcant/Cont or to
EXHAUST HOOD(W/DUCT) -
CONSTRUCTION TAX PAID:
HAZARD S MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
-
Will the applicant or hr bullding occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Date Receipt#
FIEATING UNIT (OVER 100,000 BTI.
—
TOT
I1,.It Yaensd Safety Code, Sectlion 25532(.)7
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
Will the applicant or❑future building occupant use equipment or devices
which Chat baurd.... it contaminants.. defined by the Bay Are. Air
Quality Maragement District?
Yes ❑❑ No
(� have read the h=Rous materials requirements under Chapter 6.95 of
I D,
BOILER-COMP(3FIP OR 100,DM BTI)
BOILER- COMP (OVER I00,DDO BTU)
the California Flea)th k Safety Code, Sections 25505,25533and 25534. 1
understand that lithe building don not currently have a tenant, that it is my
AUG 'I 11�(��
AU/ s7
NEW RESIDENTIAL MECH. SQ.FT
responsibility to notify the occupant of the requirements which at be met
prior to Issuance of a Certificate of Omrpa ncy.
CITY Ur
ISSUED
Owner or zuthorle agent Date
L. r�
OFFICE COPY