23543 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PPRMITNO.
BuBding� A 3,600 V1-0e E 23543
era came: one:
CITY OF CUPERTINO-BUILDING DIVISION nn
Contract .a1"anp Lk•"° APPLICATION if PERMIT `� —21-7 Com,
• Nau� BULDINCELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROLN
Ar It'd/Cn neer. Lk.N.; -
- �� QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addrcse22400 VjA L%&ffV--0rg ( POWTISSUANCE f0 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l are licensed under provisions of Chapterg(conamme, APPLIANCES RESIDENTIAL JOB DESCqWION
ingwithSaction.11f.m d ldfaon39fthe Butlnessand PmleselonsCade,and my
Iirenmblass force and site d. PANELS
License CWm Lk.N l/
Dale ContractorUP TO 2DO AMIJ�5
ARCHITECTS DECLARATION 201'10)0 AMPS
µqqµ!!0M O I understand my plane shag be used as public records. OVER 1000 AMPS SQ.Fr.FLOOR AlrPA $/SQ.FT.
E Licensed Profemlaral STGNSELECTRICAL �� � ' 1
<z OWNER-BULDER DECLARATION II
z A
ra
Ihercby al0rm that[am exempHromthe Contractor's License Law for the SPFOIALCBXCUT/MISC d"'s
gqqqqq (o1l.wingreason.(Sectio.7reltto oslnem andr,impr improve,
Code:Any it ER
C t'uM rountywhich rcqulmea permit to ronetmd,aller,lmprove,demolish,arrcpair TEMP. OR POLE INST.
as anystmen,m prior to Its Wuance,alse requires the applicant fmauch permit to POWER DEVICES /
0k a signed statement that he b licensed pursuant to the provl'lone of the
G S
Ow1- Contractor'sLicense Law(Chapter9(commencing with Section 7000)ofOwl.
�0:1 uonI or the Busineuand ProfemlmaCode)orMat he fit exempt therafromand SWIMMING POOL ELECTRIC � VALUATION
Q.•577 the baA%forthe alleged exemption. Any vi.Id m of Section 70315 by any OU7LETSSWITCHFSFUCfURFS
appH.nt for a pemdt..bjed.the applicant to a dull perulty d na marc than N
Ov�c(,un s cci owner
hepr. NEW RESIDENTIAL ELECTR SQ,FP, STORIES TYPE CONSTRUCTION
�n u I,as owner of the property,or my employees with wages a their sole
compensation,will do the work,and lheetructure b not Intended or offered for
Cl sale(Sce.7014,Busies and Professem,Code:The Contractors License law
$ does not apply to an owner of properly who builds or Improves thereon,and CCC.CROUP ftI5.UNITS
doeseuch work himself orthrough Ms own employees,provided that such
Improvements are am Intended or.fferedfor sale.if,however,the building or TOTAL:
improvement b sold within oneyearofcornplctlon,the owner-builderwlll have
tlt,jiurdea of provingthat he did not build orlmprove forpurpoacofukJ. QTy, PLUMBING PERMIT FEE FLOOD TONE APN
U L ae owner of the property,am exclusively contracting with licensed PERMTTISSUANCE
contractors to ronelrud the pmj ct(Sec.7074,Business and Professions Code:
The Contractor's License law does not apply Wan owner of property whoALTER-DRAIN&VENT-WATER(EA)
Wo
ilds or Improves thereon,and who contraem contracts for such pko) with a FEE SUMMARY
°�3RR(Tactm(a)licensed pursuant to the Contractor's License Law, BACK PLOW PROTECT.DEVICE �� (�
on
L)I am exempt under Sec B k P C for this rescan
OUTSI OF FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECIII'1'N
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N
01 hereby aRlrm that 1 have ocertificateInsurance
c of consent m opy tram,ora RECED'f N
certificate.fWorkere Comperoatlonlmunnre ora artlrkd ropythemof(Sec. GAS EA.SYSTEM-1 INCAOUTLL75 PARKFEE Y N
Polis Lab C.)
Polirya RECEDING P1701 M
GAS EA.SYSTEM-OVER 4(EA)
Cor^ nY BUILDING DI VISION FEES
�CedEBed copy is herebytehed. GREII/WDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
ertlfled espy b filed withh the city impaction division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEW SAMT•ARY-STORM EA HpFf Date Recel t#
(Thlesectian need not he camplded It the permit b re
forone hundd dollen
($10)).rlem.) WATER HEATER W/VENT/D erTR ENERGY FEE Y N
I cartifythat in the performance of the work forwhich this perm 's
it is 'ued,
I shall not employ any para..In any manner W m to became'ubjed to the WATER SYSTEM/TREATING
Work.ra'Compenullon Lawaof C.ii(omla.Date PAID
0 Z Applicant NEW RESIDENTIAL PLMB._SQJr. Date Revel tft
Z O NOTICE TO APPLICANT-.If,after making this Certificate of Fxemptlonyou
I" 'h.uldbecome subject to the Worker'Compensation pmvbloneoflbe Labor TOTAL:
rn Code,you at forthwith comply with such provbbraor lhbpermitahall be
j deemed revoked.
BUILDING FEE
U.1
CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby a(@m that them I,.construction kndlng agency far the perform ELECTRIC FEB
Z anceofth.w.rkforwhlchthb Ix,mit bbsued(Sec.30W,CIv.C.) - TOTAL:
U O Lander:Name — PLUMBING FEE p^
LL ~ Lendce.Address QTY. MECHANICAL PERMIT F8E MECHANICAL FEE
OO 1omifythatl have read lhbapplleulorani nate thattheab°velefamutlon
1 Iscorrcd.I agree to comply with all cltyand rountyordlwnum and statelaws PERMIT ISSUANCE FEES PAID:
relating to building construction,and hereby authorlae representatives of this
Z city to enter upon the above mentioned property for inspection purposes. ALTER OR ADD TO MECH. Dale Revel [#
V — (We)agree to save,Indemnify an d keep harmless the City Of Cu pert Eno - P
aga1. liabilltks,' gene-,code d expenses which may In anywayaccrus AIR HANDLING UNIT(T010,000CPM) SUBTOTAL:
ag.Wt said o..qu the grant Ing of this permit.
�� Z AIR HANDU NG UNTr(OVER I g000 CFM) CONSTRUCTION TAX
Signature or pplian/Contractor Dale EXHAUST I IOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willtheapp[lanl or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
moterialas defined by the Cupertino Municipal Code,Chapter 9.17,andlhe Date Reeei t#
health and SafetyCode&lion 25532(a)2 HEATING UMT(OVER 100,000 BTU) TOTAL:
❑ Yes �No
Wlli the applicant re future Wilding occupant use equipment or devices VENTILATION FAN(SINCLE RFSID) ISSUAN ATE
which emll hamrdou'air contamina nm as defined by the Bay Area Air pk N
. Quality Management DisWd7 BOILER-COMP OHP OR 100,DDO BTU r !'a
(-1 Yrs I�I No
ave
the harar .usmaterials requirements under Chapter 6.95 of BOILER-COMP(OVE 1(0,000 BTU) APR 7.72
the California Health h Safety Code,Section'25505,25533 and 25537.1 e
understand that if the building dace not currently have a tenant,that It b my NEW RESIDENTIAL MECH. SQ.Fr 2S 1.[](�
rrspamibll try to net lfy the occupant of the requirements which moat be met )
prior to Issuance of a Certificate of Occupancy. "'fl Y 4,)r Gu t,Cf11 114U
Owner or authorized agent Data ISSUED BY: �(.-
TOTAL:
OFFICE COPY