23590 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Build Ing Addmu:s It*& Z 3 5 9 0
weer. ams: ane: (yA, APPLICA IION hUBMI I I A
I ,CITY OF CUPERTINO-BUILDING DIVISION I
Cont d s car: Lie.No: APPLICATION / PERMIT _mo,1'2 Z
AM BU(LDING-ELECTRICAI.I'LUMBINC-MECHAMCAL CATEGORY COWfIft
Arch grocer. - Lic.No:
'QTY ELECTRIC PERMIT FEE BUILDINGPERMIT INFO.
Address I'FRFBTISSUANCE — rx tK
LICENSED CONTRACTOR'S DECLARATION
Ihereby edionmthat lamlkenud under eBuM rvlandPmfChapter odCandmy APPLIANCESIiESIDENTUl JOB DESCRIPTION
inense i Section force and Affepn3ofthe Buslneuand ProfnNona Code,and my
license isle full force and c.N PANELS l
License C6ee Lk.p
Dale Contractor
ARCHITECI`S DECLARATION 201-1000AMPS
WZ I understand my plans shall be used as public remrda. OVERIODOAMPS SQ.Fr.FLOOR AREA $/SQ.Ff.
00
E (Oj Licensed Professional SIGNS ELECTRICAL
!! LG$ OWNER-BUILDER DECLARATION
}-n SPECUL C/RCl)T/MISC
owingitcrerasormlhnlamexemptfromthe Condessio•Llcense Lw fort he
following reason.( crape 700t to Business mtmd and Pmfesaions Code:Any tlty it
O P TQdP.ME1TR OR POLE INST.
arystywhkh requbesa uscancocoo requialter, apmvert forslah,orto
$ < any stmdure prionto statement
that
he is lied sed pursuant t the rovidos,ofpermit e POWER DEVICES
TNG O IIIc a signed statement that he la licensed pursuant to the provL+lom of the -
OwG Conradoes License Law(Chapter 9(commencing with Section 7000)olDivi.30 sion3ofthe Bus cowed Proleulom Code)orthathebemmpitherefmmand SWIMMING POOL ELECTRIC VALUATION
O the basis for the permit
alleged u exemption. Any violation of Secpenalty
o net m re any UTLETSSWITCHFSIIXTURESrob u
applicanthudred fora pll..(S subjects the applicant toe civil penalty of net more than — t
fivchundrdderoft(f500). SQ,Fr. STORIES TYPE CONSTRUCTION'
I,as owner of the property,or my employed with wages as their sole NEW RESIDENTIAL ELECTR
compensation,will do the work and thestmetum is not intended or offered for
o sale(Sec.7044,BusBauend Prefesnou Code:The Contractors License Law
�$ does not apply to an owner of property who Wilds or improves thereon,and OCCGROUP RFS.IJNITS
who dodsuch work hureciforthrough his own employed,provided that such
Improvements are not Intended oreffered tarsale.If,however,thebullding or
m
Improveent b sold within oneyear ofcomplMion,the owner-bullderwill have
QLktrden of proving that he did not Wild or improve for purpose ofule.). dTY, PLUMBING PERMIT FEE HADD ZONE APN
L-,I L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contnctoes to mostrud the project(Sec.7044,Business and Ikofesscaou Code:
The Contmdor4 License law does net apply to an owner of pmpemy who ALTER-DRAIN kVENC-WATER(EA)
Wilds or improves thereon,end who contracts for such projects with a �^
uiji4actor(s)licensed pursuant to the Contractor'.License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJI am exempt under Sec B k P C for this reason
Owner DRAINS FUDO4,ROOF,AREA,GOND. SANITARY Y N
Date RECEIPT#
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP _SCHOOLTAX Y N
QI hereby affirm that I have a¢rtlBrate o!consent to seI-insure,ora �• RECIyPf M
mnifluteof Work� Compereationlnaurancenracedifledmpythe=((Sec.
3800,lab C.) GAS F.A.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Policy# - - RECEIPT M
Com an GAFA.SYSTEM-OVER Y S BUILDING DIV]SI NITES
Caddied copy 1s hereby fu dwith the
city CREASEANDUSIRL WASTE INTERCEPTOR PLANCHECK E
�CertIfIN copy,V filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP - PAI _ �r
COMPENSATION INSURANCE SEWER-SAAND.ARYSTORM EA 200F1' to Recef t#
(fhlssectionneed cadWENSATI NI permit bCosinehundred dollars
(8100)orlces3 WATER HEATER W/VENT/ELECTR EN' YFEE �a
I snotify that In any pehe r on in any mannerhe work so as tobeco pesubpormit Is Ito theed, — (Vj
1 shall not employ any Laws an any mannerso u to become subject to the WATER SYSTEM/TREATINGto
Workers'Compensation laws of California. Date PAID
-
0 Z
Applicant
Z O NOTICE TO APPLICANT:If,ager nuking this Certlfiule of P.xemptbn,you NEW RESIDENTIAL PLMB.__SQ.IT. Date eWl t#
should becomesubject to the Workers'Compensation provisiomofthe LeWr - TOTAL:
N Codgyou mustforthwith comply withsuch provisions orthls permit shall be BUILDING FEE 3
> deemed revoked.
aa CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby alflrtnthat there Is a construction lending agency for the perform- ELECTRIC FEE
D Z arca of the work!or which this permit la Issued(Sec.3097,Civ.C.) T L
02 lenderb Name PLUMBING FEE �.
IL F LcndereAddress QTY. MECHANICAL PERMIT FGE MECHANICALFEE
OW 1certlfythatl have reacithis appllcadonand statethatthe above Infer it..
1 bcerrect.]agreetocpmply withelldty and county ordinances and elate laws PERMIT ISSUANCE FEESPAID:
relating to building comtrudlpn,end hereby authorize representatives ofthis
Zcity to enter upon the abwv nrcrdlomed property for Inspection purposes. ALTER OR ADD TO MECH.
— (We)agree to save,Indemnify and keep harmless the City of Cupertino 1 - Date Receipt#
.gal halide judgment ,m • nd expenses which may In anyway accrue . AIR HANDLING UNIT DO 10,030 CFM) SUBTOTAL`
aga' is Id CI in en he granting of this permit.
AIR HANDLING UNIT(OVER 10,"CFM) CONSTRUCTIONTAX
Signature of Applicant/ContractorDate EXHALSf HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCCeI t#
material as defined by the Cupertino Municipal Code,Chapter9.12 and the
I ealth and Safety Cade Section 25532(a)I HEATING UNIT(OVER 10,000 BTU) TOT
M Yes No
Will the a pplicant or tore building occupant use equipment or d evicts VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which emit hazardous air contaminants as deBrud by the Bay Area Air
Qu a lity Management Dist rid? BOILER-COMP(71I'OR 100,0M BTU)
❑Yas n❑No
I have read the hanrdo.,matcrl.lsmrc(ulrementsunder Chapter 6.95 of BOILER-COMP(OVER100,000 BTU)
theCalifomla Health&Safdy Code,Sectiou2550S,ZB3and25534.1 A g p�
undemt.ndthatifthe Woe.
lldingdnmcurrentlyhaveatenant,thatitbmy NEW RESIDENTIAL MEINA
. SQ.Fr. 1 6J
responsibility to notify the occupant of the requirements which moat he met i
/1
' prior to Issuance ofaCertlfkate ofOm1{pancy. V�la7� r /I
Owner or authorised agent Data
ISSl/E
TO
OFFICE COPY