23837 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: 23837/'1(1
mere arae: one:
CITY OF CUPERTINO-BUILDING DIVISION
Contia°°r°"' Lie."°: APPLICATION / PER IT
Lie.No: BOLDINGELECTRICAL-PLUMBIN HAMCAL CATEGORYCONTROL a
Archl ct Engineer.
PTY ELECTRICPER T FBUILD INGPERMITINFO
Address: PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter9(commume, APPLIANCES-REFDOMT. JOB DESCRIPDON
IngwlthSedion7000)of DlWs(on3o(the Businesaand Prolesslona Cade,wd my
It...Is In fun force and effect. PANELS
License Class Lie,
Date Contactor
ARCHITECTS DECLARATION 101 ps
ki 111V .1
ceO Z2QQ�, I understand my pbru sham be used as public records CIVIR1000 Amps rl v SQ.ET.FLOOR AREA $/SQ.Ff.
I9 40
LicensedProfnsimul CNSELFCTRICA 2Z 230
H OWNER-BOLDER DECLARATION SPECIAL CIRCUIT/M
z t-, 7a Ihercbya(flrm that lam exempt from the Contractors License Lawlor the
following reason.(Section 7001.5,Business and Professions Code:Any city or
FF' county which requires a permit to construct,*list,improve,demolish,oreepalr 117dP.METCROR LE INST.
any stmetum prior to its Issuance,also require.the applicant for such permit to
rYG file a signed statement that he is licensed pursuant to the provisions of the POWER D B
Ow Contractors License Law(Chapter 9(commencing with Section 7000)ofDIvI-
F,30 gm3 oftlu Rutin.and Profeselora Code)orthat helsemmp"lurafmmand SWIMN9GPOOL ELECTRIC VALUAT16o
Sn the bash for the alleged exemption, Any violation a(Sactlon 7031.5 by any CCJJ
TCHESEXITJRFS
applicant for a permit subjects the applicant to a civil penalty of not more than O ETSSWI `
ve Ilftmd dollars($S=.
owner of the property, NEW RESIDENTIAL ELECTRSQFr, STORIES TYPECONS(RUCTION
(^a p perry,or my employees with wages r thele wh
c &c.7 on,will Business
uss ethe ss and r mssions mdumls not License
ed for
Law
D h(Sec. ppil,to art osamif property Code;The or Improoe.ves
Wmtue Law
�$ oe.no suchwrk owner ofproperty who bulids
mprovnded that,md OCC.GROUP RFS UNITS
who
ovemo team n hMveBathreughhis own .If,ho employees,p however,the
building
h
Improvement am nor trended earofcomproffered r.ale.the menvet, deer ill have TOTAL:
improvenonl lswldwithin one yearo(complefWn,theowner-bunderwlllhave
t1LIiurdm of proving that he did not build or Improve for purpose of sale.). QTy. PLUMBING RMIT FEE FLOOD TONE APN
U I,as owner of the property,am exclusively contracting with licensed PCRMIT ISSUANCE
contractors to onnetmd the project(Sec.7044,Business and Professions Code:
The Contractor's Llmme Law don not apply to an owner of property who PETER-DRAIN&
builds or Improves thereon,and who contracts for mch pRojects w!th a EEA)
c, actor(a)licensed pursuant to the Contractor's License Law. FEE SUMMARY
EI am exempt under Sec. B&P C for this reawn BAIX FLOW PROTECT.DEVI
Owner Date
DRAINS FLOOR ROOF,AREA, SANITARY Y N
RECEIPT a
WORKMAN I have.COMPENSATION DECLARATION FO(TURE^.PER TRAP SCHOOL TAX Y N
01 hereby affirm that I have o Ingura le of current to copy
ora RECEIPT if
cedlficateofWorkeri Compenvtloniruurance oraartBhd copythereof(sec. GAS FA.SYSTEM.1 WC40 PARK FFR Y N
Policy
lab CJ
Policy M rt
RECEIPTM
CaGAS EA.SYSTFM-OVER4(EA) BUILDING DIV
ISION FGESmCeyifed
copy h hereby tthe city
GREASE/INDUSDIL WASTE IMERCEP PLANCHECK FEE I:-11q9
: 1 q 9
Certified copy Is filed withh the ty Inspection division. J
CCRTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date Rewi t#
Uhlssectlon need not be complded If the permit ls(Drone hundred dollars
($10))crimat e.)
WATER HEATER W/VENT/FLFCTR ENERGY FEE Y N
Ill nor employ
any person
arhe s n in anfthewoek.se to beconsh this emnit is tined,
I shall not employ any perwnln any manner w u to become aubjuct to the WATERSYST.PM/TREATING "
Worlicre'Compenutlon Lawn o(GII(omt.DataPAID
O Z ApplicaNOTICE
NEW RESIDENTIAL PLMB. SQFf. Date Rewi t#
_Z O NOTICETO esubje subject
after rs'Comakinper Certnlpro o(Exemptionof the
you
Code, becomesubjecttothe Work an'Comp rovisinprovhlomofthe Gbor TOTAL:
F y
Code,you inked.forthwith comply with such provisions or this pemNt.hall be BUILDING ••
� j deemed revoked. �
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
d (hereby affirm that there is a construction lending agency for the perform ELECTRIC FEE
M Z ance of the work for which this permit is tmed(Sm.3097,CIv.Q TOTAL:
o O Tender'.No PLUMBING FEE
ILS Lender.Addreas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O U
UIcedlfythat l have madthhapplicatimand slatlhat iheabovelnformatlon
IL is correct.Iagree to comply with all city and county ordinances and elate laws PERMIT ISSUANCE FEES PAID:
N relating to building construction,and hereby authorise representatives ofthi.
F Z city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH. Date ReCCI t#
V _ (We)agme in save,Indemnify an d keep harmless the City of Coped Ino
agalrest B.bilitlss,judgment,costa and..pan.which maylna ways a AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City In consequence of the Sr.ming of thispp/fnIt �/
(fl b AIRHANDLING UNIT(OVER Io,000CFM) CONSTRUCTION TAX
IgnaNrc°(Applicant/Contractor Date EXHAUST HOOD(W/DUC) CONSTRUCTION TAX PAID:
H 1;A1C0 USMATERIALS SC SURE
WIIltheapplica ntorfutumbundingoavpant at or handle havadous HEATING UNIT CED 100,000 BTU) Date RCCCI f#
matedal as defined by the Cupertino Municipal Code,Chapter 9.11,and the
Health and Safety Code Section 25532(a)1 HEATING UNIT(OVER 100,000 ETU) TOTA
F1 Yu N No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which colt hamrdous air contaminants as defined by the Bay Area Air
Quality Management Dwrid7 ROME R-COMP PHP OR 100,0M BTU)
Yes ❑No
the ahave read the hat.12 uamaledah requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) q
ifernt Health&SafetyCode,Seal.o 25505,25533 and 25534. I - a'9
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT
responsibility issue
nfatythe ompantof theccupa requlrcrant which mus/bemet UAI '0�
prior to Lssuanm of Certificate of Occupancy. H 1�
4r�
Owner or authodred agent Cpl�
Date TOTAL: ISSUED BY: VGJ t
OFFICE COPY