23447 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES'-USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Addmas: . ' Ile ��, /l, J � ��
�o ��s ��e. �� '�r � K 23447
- oar. I Phone: - A
Gt TSZ - CITY OF CUPERTINO-BUILDING DIVISION
fra Name: APPLICATION / PERMIT
BUILDING-ELECTRICALI'LUMBING-MECHAMCAL CATEGORY CONTROL N
Archi act/Engineer. Lie.No
-• - t7 ..rrte� Qrr `t jj t ;BLECTRIG PERMIT I11 It{ '� 'FEE t t ;'t".BUILD W G,PLRMIT INFO, '.;M
Aaarcn:()fys—{�QSl1w/VCw ttW /'(d(•-� PERMITISSUANCE
LICENSEDCONTRACTOR'SDECLARATIOK;?�gaI{'�//�� - _ � 0 -
1hereby affirm that l am licensed under proviefic o(Chapfgf97mmi�Tenc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwlth Se On7000)o(Division3ofthe Buvnemand ProfasionsCode,and my ��
license is In fuB.9oym�d effect' -1 PANELSHi
License Class C.0 !'.Lk.N�/S��Z� ,/s�
rp
Date Co firactorARCHITECT'S
94�• a J `T
ARCHITECTS D[CGRATION - OVER00 AMPS "
I understand my pli ru ehaB be used as public records. - OVER 1000 ANTIS �.FT.ILOOR AREA $/SQ.FT..
ZSIO
(/ Licensed Professlarsl - SIGNSELECTRICAL '
. 6 OWNER-BUILDER DECLARATION SPECIAL CIItCUIT/M1SC
Zl.,, a Ihereby.M.that l am exempt from the Contractor's License law for the -
pp following reason.(Section 7011.5,Business and Professions Code:Any city or i
OM[=.amit TEMP.METER OR POLE INST,
�� .-1 cwtractu hrequiriftiii
.ace,aI,.conaq.,alterthe,
tlennuch,orto _
.a ale,.signed
cturc tatemeita that
his is licensed renniant p the pro for inionsofpermit e POWER DEVICES'
c. file a signed statement that he t licensed pursuant it the provisions of the
3wI. Contraciorb License Lew(Chapter9(commencing with Section 7W0)o(Divi.ro SWIPQMING IDOL ELECTRIC I,.
X0:7 cion 3 ofthe Business and ProfessloCode)orthat he is exemptthercfromand 1�VAI.UA� j
a.•�]] the bud.for the alleged exemption. Any violation of Section 7011.5 by any OUTLE7SSWITCHESFIXTURES
applicant fora perodt subjects the applicant to a civil penaltyof nor more than
five hundred dollars($500). NEW RESIDENTIAL ELECTR SQ.FT.
Z ❑I,as ovmer of the property,or my employees with wages as their axle STORIES TYPE CONSTRUCTION
compensation,will dothe work and theslructure le not Intended or ofamd for
' sale(Sec.7094,Business and Professions Code:The Contracim's License law _
don not apply to an owner of property who Wilda or improves thereon,and OCC.CROUIa RES,UNITS
E who dacasuch work Mmselforthrough his own employees,provided that such "-
improvements are not intended oro(fered for sale.If,however,the building or TOTAL:
Improvement lssold within oneyearofcompletion,theowner-bufiderwlll have ., q'I
th�rden of pmving that he didnot build or improve for purpose ofsale.). QT,Y, 'a��,� K TWINE PERMITt �.qr,r' ;j FEE,' FLOOD ZONE APN
4 as owner of the property,am exclusively co..... ng with l—o— PERMIT ISSUANCE
contractors to mnstmct the project(Sec.7044.Bualness and Professions Code:
The Contractor's Lirenee law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EsU
Wild.or Improves thereon,and who contracts for such ptojecte with a reaFEE SUMMARY
m,B¢actorts)Banned pursuant to the Cantraeor'a License Law.' BACK FLOW PROTECT.DEVICE
I ' l�' -
LI I am exempt under Sec. B k P C for this son
•
GRAINS.FLOOR,ROOF,AREA,GOND. SANITARY Y _ N OUTSIDEFEES
Owner - .Date -❑ =
artifi
WORKMAN COMPS DECLARATION FIXTURES.PER TRAP SCI{OOL TAX Y_RECEIPT N I hereby affirm that I have a certlBato te of co m self-insure,or RECEIPT N
3800,ab ofWorkere Comperoatlon lruurana ora artifled ropy fhemof(Sen GAS EA.SYSTEM-1 INCA OUTLETS PARK FFR Y N
PolicCam q GAS EA.SYSTEM-OVER4(EA) RECEIPTN
Com any BUILDING DI VISION IT IS
CacAlfiedm
ropy le herebyfurnished.the city CREASE/INDUSML WAS IEINTERCEPTOR PLANCI IECK FEE
• ❑Certified copyle(Ikd with the city lrspectlon division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE , SEWER-SANC['ARY-STORM EA.2(IOFT. DdIC RCCCI I#
(This section need not be completed If the permit le for one hundred dollar'
'($100)orless.) WATER HEATER W/VENT/F].ECTR ENERGY FEE Y N
1 artily that in s
the perforence of the work for which this peunit In Isnaed,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREANGTI
Workere'Compenatlon laws o/GI1(ornla.Date PAID
O Z Applicant - - NEW RESIDENTIAL PLMIL SQxT. Date Recei t#
Z O NOTICETO APPLICANT:If,after making thisCertlflate of Exemption,you
should bemmesubjectto the Workeri Compersatlon provlslors offle Labor - ' TOTAL:
N
Code,you=at forthwith comply with such provisions or this permit shall be
FEE
LU j deemed revoked. B G
CONSTRUCTION LENDING AGENCYSEISMIC FEE
a C dhembyaffirmthatthem iia ronstruelon lendingagenry forthe perform- ELECTRIC FEE
Z ana of the work for which this permit is Word(Sec.3097,Cl,C.) - TOTAL: ,
(� O Lender.Name - - - .PLUMBING FEE
LL F Lender's Addm.a QTY. 1'' MECHANICAL'PERMIT' L `, FEE; MECHANICAL FEE
OW 1artilyfhat l have read this application and statethatthe abovelnformation -
1 brortect.I agree to comply with all city and county ordinances and stale laws PPRMI'FIS5UANCE FEES PAID:
} Nrelatingtobuilding.vtmat..,andhercbyauthor mpmwntative.otthb - -
H Z city to enter upon the above-mentioned property for impecclon purposes. ALTERORADDTOMECH. Date .ReCel t#
V ' (We)agree to save,indemnify an d keep harmless the City of Cupertino })
against BzbllWes,judgencons,"asit4aelIpmes which may Insole ways.. AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL'
aga Id City eequenreo canting of this pesnit.
?s 7 /� AIR HANDLING UNIT(OVER I0,000CFM) CONSTRUCTION TAX'
Sigwlureo ppBant/ untractur Date EXHAUSTHOOD(W/DUCD - CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE -
t Will the applicant or fflumbuddingoccupant.tore orhandlc h.ndom lirATING UNIT(TO iffl,000 BTU)-
moteria I as defined by the Cupertino Murldpa I Code,Chapter 9.17,and the Date Reee' #
Health and Safety Code Section 75537(a)? HEATING UNIT(OVER 100,000 BTU) TOT
qYes MN.
UI applicant or futum building onvpanl use equipment or devices VENTILATION PAN(SINGLE RESID). ISSUANCE DATE
which emit haeardous air contaminants as defined by the Bay Area Air -
® Quality Management District? - - BOILER-COMPOIIPORIOB"BTU)'
NoBOLRCOMP(OV100,OB )
thehavercadthehar.❑usmucrialsrcqu+rementsunderChapter6.95ofPAID
$
A I U
California Health A Safety Code,Sections 75505,75533 and 75534, 1 -
understandthatif the building does not currently have a tenant.that It E my NEW RESIDENTIAL MECH, SQ.FF Itat
msporsibility to notify the occupant of the roquircments which most be met yB/IID vj (/�.''.yl�-�y{•
prior to Lssuancc of Certificate of Occupancy.
WAR 24 196\1�Y_J
Owner or authorized agent Datet _
TOTAL: ISSUED BY:
OFFICE COPY