23779 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMM]T NO. -
BuBding Address: - - - ^^3VMn
Zoi tl S. 4� L b D G
Owner's 'no A
L time p. CITY OF CUPERTINO-BUILDING DIVISION
ora a LIc.No: APPLICATION /PERMIT
Wit En BUILDING-ELECTRICALPLUMBINC MECHANICAL CATEGORY CONTROL M
Bin t y Lic.Nr ...
gbLr•r�0_S oak QTI''''' I'�ELECTRIC PERMIT/ I �FGE'� I .';.'IBUILDING'PERMIT;INFD r '•'
Address:- PERMITISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION -
I hereby affirm that l amlicensed under provislossof Chapter9(mmmenc APPLIANCFS�REMDENTIAL JOB DESC 'ION
ingwith Sedt.n7000)of DiN,i.n3ofthe Buslnessand PmreasionsC.de,and m T
license ie in full icimeand d(ect. PANELS
LlcenseClam Lich
Date_ Conmador -
ARCHITECTSDECLARATION 2014000AMPS
X2 I understand my plansahall W used.public records. _ OVERIODDAMIS SQ.FT.FLOOR AREA L 11h f/SQ.FT.
E z Licensed Professional SIGNSELFGTRICAL
<6
OWNER-BUILDER DECLARATION 12S"N'
En• $PEC7ALCIl2CUIT/MISC
owing yarO,. that&eti am 7031S,exempt four,Business
a d Profession.icanse
Any
city or 1,
following reawn.(Sectl.n 70315,Bualncss and Pro(essmns Code:Any tlty or
caantywhichrequimsapermhmmmmd,alter,impmve,demollah,ormpalr TEMP.MLTFR OR POLE]NST. ,
q`� .a anystndure priorto lte lssuance,aW requlreathe appBrant!.Touch permit to POWER DEVICES
file a algned statement that M b licensed pursuant to the provtslom of the -
3nContractor.License Law(Chapter9(commencing with Section 7000)of Divi- VALUATION
Ian SWIMhIINO POOL ELECTRIC
� � the 3 of bass he for the
e d Professions AnyCode)viothat lation f exempt therefrom and �� ��� CXj
the bran for the alleged exemption. Any violation of Section not ca by any OUTLETS-SWITCHES.yo$ ' applicant fora permit aubje<s the applicant too tivll penaltyof not more than a
ccs R five hundred dopase(SM. - -
�n ❑I,as owner of the ro NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONS RUCTION'
p perry,or my employees with wages r their dole
C
compensation,wusdothe ess and rit,and tnestmc[umh Contractorot Intended o icame offered Law
O vie(sec. pply to Business and fproperty
ropstProfessions Cadn:The Contractors Llceme law
$ whododoes tapply torn.wnerorpTough who nem orimproovidedreoRand
who daeesuNwork himsel(orthrough his ownemployces,provided that such OCC.GROUP RIS.UNITS
Improvements are not intended oroffemd for sale.If,however,thebuildleg or TOTAL:
Improvement lssold within oneyearofcompldWn,theowner-WBderwlll have
thAkurden ofpmvingthat Mdid not build or Imp Qiy, '_�j'+;f.PLUM BINCPERMIT�','�t''�I * ', FEC.' FLOOD TINE APN
u 4 as owner or the property,am exclusively mntratling with licensed PERMIT ISSUANCE r r D
mituactors to constmet the project(Sec.7040 Bwinem and Professions Code: >s
The Contractor.Llmese Law does not apply to an owner of property who � I k dWA,I'FR
Wilds or Improves thereon, and who contracts for such ppn*ts with a - �� ' FEE SUMMARY
c admix)licensed pursuant to the Contractors License Law. t
c(51 am exempt under SC_ec B k P for this reaction
_ .ACK, yW
Owner Date '• �y [y��a.lsyy�' SANITARY Y_ N_
WORKMANCOMPENSATIONDECLARATION I-� `�'- / T'a RECEII'
TI-
MI hereby affirm that I have a certificate of consent to self-Insure,or a SCHOOL TAX Y N_
cedifioteof Workers Compensationlrwumnmar renified mpythereof(Sec. RECE1T7#
3800,Lab C.) ' - 4.- GAS EA.SYSTEAi-I INCA OUTLETS PARKFEE Y_ N_ .
PollRECEPT If
Policy p CAS EA.SYSTEM-OVER 4(EA)
Com any BUILDING DI VISI FE 115
�Cerltied copy v hereby furnlahed. CREASE/[NDUSIRL WASTE INTERCEPTOR PLANCI-IECK F-CyI'
jacomfied copy is filed with the city inspection division. Q -
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PA/- �/N//
COMPENSATION INSURANCESEWER-SANITARY-STORM EA.2(OFT. xl % a- -, RB i IN
(This sectl.n need not M completed if the pemot in for one hundred dollars
ENERGY PEE oN
(fi(D)olet
I certify le thh at N the pcperformanceof the work f.rwhlch this permit Is Issued, WATER HEATER W/VENT/PIIECTR /a
I shall not employ any person In any manner no as to become subject to the WATER SYSTEM/TREATING '
Workers'Compensation laws of California.Date PAI D
O Z Applicant NEW RESIDENTIAL PLMB. SOFT. Date Recei til
Z O NOTICE TO APPLICANT:If,after ma king this Cerillote of Exemption,you
should become subject to the Workers'Comperomlon provlelona of the Labor TOTAL:
N Code,you most forthwith compiywithsuN
ch provisions permit be
W — deemed mocked. BUILDING _
W > CONSTRUCTION LENDING AGENCY - SEISMIC FEE _
a.0 Ihereby affirm that there is a mrotrudion lending agency for the perform- TOTAL: ELECTRIC FEE
7 Z oncedthe work for which this perMi VLssued(Sec.3097;C1v.C.)
U O tenders Name PLUMBING FEE
LL I- Lenders Addreda QTY. '.? .I MECAAN_ ICA_L`PERMIT _ FEE
O W 1certifythat l have read thbappilcationend statcthattheabati
ovelnformon - MECHANICAL FEE
a Vcom,ct.l agree to complywith all city and county ordinances and crate laws PERMIT ISSUANCE FEES PAID:
N
relating to building constmctlon;and hereby authroW representatives ofthls
city to enter upon the above-mentioned property for inspectionpurposes. ALTER OR ADD TO MECH.
� -
Z (Wed eto ravem
,Indenharm
leas and keep haress the City of Cupertino Date Recei t#
-
awtlleblllt gmenb,coateand expenses which muy in anywayamue AIR HANDLING UNIT(I'010,000 CPM) SUBTOTAL:
aga tsald I in ns uenre of the Bran Ungofthlape IL
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
sign m art pPBe�ancanbad � ate FxHAUB'r Hooq M/DUCT) CONSTRUCTION TAX PAID:
�fA;V RDOUS MATERIALS DiSCLOttt999uuuRE '
Will the applicant or future building occupant atom o ban hazardous , HEATING UNIT,(TO 100,000 BTU) Date ReceI tit
material as defined by the Cupertino Municipal Code,Chapter 9.I$and the
I fealth and Safety Code Sectio 32(.)7 HEATING UNIT(OVER 100,0(10 BTU) TOTAL: .
❑Yes - -
WilltheappEantorfutumbuilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCEDATE ,
which emdl baeardous ab mntammnanls as defined by the Bay Area Air p
Quality Marugement District BOILER-COMP QHFOR 100,000 BTU) P ,A � 'D '
4Yes o
b.vereaHealtaza�materiabtionsmcn underCM1aper6.95of BO LER-COVP(OVFR100,0gBN) AUGhe CallrornU Health A Safety Code,Sections 25505,7SS33 and 25534.1 - ` ./1 7 1992
understandthat lithe building does not currently have a tenant,that it my NFWRESIDENTIALMECH. SQ.FT
o n occupant of the requimments which must W met '
pdortoissuan aCcrtfimteof Occu nq.
2 CITY Ur uurcnulvu
owler or au xec agent ISSUEDBY:� U—uj 5
TOTAL:.
OFFICE COPY