23535 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PIRMITNO.
Building Address: 23535
/b Z L i G,T'
wncr s
ate. 71 ,T(f yy -1!ry7 CITY OF CUPERTIN0.6UILDINC DIVISION
• a tra"araName: ./d Lk.Na: APPLICATION / PERMIT
.I Kezwor ��'` T+ C'f" LDINGG
ELECTRICAPLUMBINC-MECHA CATEGORY
BUI
Arehltea/Engineer:
d Lk.No:
/IE BUILDING PERMIT INFO
!
AofO O QTY ELECTRIC PERMIT FEE
E cft MQ PERMITISSUANCE ICS
LICENSED CONTRACTOR'S DECLARATION ��aJ
Ihereby affirm that l am licensed under pmahaons of Chapter 9(..no APPLIANCES ENTIAL BDFSCRII ON
Ing with Sm"on 7000)ofDivision 3 ofthe Business and ProfesslonsCode,and my
license le in fail fQ.and died. PANELS.
Licenx Class Lie.Y 7 7 eQ
Dale 0,.9n�-_nom-✓Contraaor- Inn "V NMI(
_D -T�ARCHITECI'S DECLARATION gmm
q�q�vv Q CCO I understand my plana shall be used as public recmde. OVER 1000 SQ.FT.FLOOR AREA $/SQ.FT.
k z U Licensed Profinabrul SIGNS ELECTRICAL
<G t OWNER-BUILDER DECLARATION
I hereby afBrmthMat l am exempt from the Contractor's License Law forthe SPLCIALCIRCUIT/M
F -
pppp following reason.(Section 70715,Business and Protractors Code:My city or
ceuntywhich requnni a permit toconstruct,alter,improve,demellsh,orrepalr IEMP.MET[R OR POLE INST.
Qanystrudure priorto its lssuance,also requiresthe applicant fersuch permit to
P O 0k
..Igned statement that he I,licensed pununt to the provisions of the (OWER DEVICES
Q6 Contractor's License Law(Chapter 9(mmmencingwith Section 7000)ofDivi.
O�^ slon3ofthe Buelnessand Pmfenlorm Code)orthathelsexemptthercfromand SWIMMING POOL ELECTRIC VALUATION
O the basis for the alleged exemption. Any violation of Stolon 70315 by any OUILEISSWI'ICIiESFIXTURES
applicant for a permit subjects the applicant to a civil penalty o(not more than ow
BvMbundrad dollars L$SM. NEWRESIDENTIALELECTR SQ.PT. STORIES TYPE CONSTRUCTION
�n I,as owner of the property,or my employen with wag"as their sok
t compensation,wBldothe work and thestrudurc is net Intended or offered for
F O
wk(Sec.7004 Business and Profession Code:The Contractors Llcenae[aw
,$ does not apply to an owner of property who Wilds or Improves Ihereon,and OCC.GROUP RFS.UNITS
whod.suchworkhim lforthrough Nsownemploye",providedthatmch
Impneverrcnb are not Intended oroffemd for sale.It,howevepthebulldlngor '[ �FEE
improvement Issold within oneyearofcompletion,the ownebullderwill have
theburden of proving that he dWrot bund orlmpmve for purposeofsak,). QTy, PLUMBING PERMIT pLOpD ZONE APN
M L as owner of the property,am exduslvely contracting with Boozed PERMIT ISSUANCE
contractors to construct the project(Sec.70K Business and Pro(esslom Code:
The Contractors License Law does no apply to an owner of property who ALIIItARAINk VFM-WATER(EN
builds or Improves thenen, and who contracts for such ptoje with a
gIlf�aMetal licensed pursuant to the Contractors License Law. FEE SUMMARY
c LJ I am exempt under Sec. B k P C for this rcason BACK FLOW PROTECT.DEVICEOUTSIDE!FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N Owner Date RECEIPT p
WORKMANI have
DECLARATION MTURFSPERTRAP SCHOOL TAX Y N
®I hereby affirm that I have a l r ra to of convent to apythe r of ora RECEIPT Y
<eal(Inte ofWerken'Compensatlonlnsuranaaracertllled copythereo((Sec. GAS EA.9YSTEM-I RVCAOUTLEIS PARK FEB Y N
Ili lab CJ
I'o1kyY^7Ll G/E-SbCDP7—Gtxx� GAS EA.SYSCEM.OVER d(EA) RECEU'fp
Com BUILDING DIVIS1011 FEES
JR Certifed copy ls hedwith the cit. GREASE/INDUSML WASTE INTERCEPTOR NCHECK FEE IY�
Certified copy ls filed with the city inspection division.
CERTIFICATEOF EXEMPTION FROM WORKERS' GRFASETRAP PAID
COMPENSATION INSURANCE
(This section need na be completed if the permit is far one hundred dollars SEWER-SANITARY•STORM EA.7°OFT. Dateeeei �.
(5100)orlen,) WATER HEATERW/VENT/FLECTR ERGYFEE N
1"rtify that In the performance of thework(orwhkh this permit le issued,
I shall not employ any person In any manner n"to became subject to the WATER SYSTEM/TREATING
Workers'Cempenntlon lawn o(Call(omla.Date PAID
O Z Applicant
Z NOUCE TO APPLICANT.If,after making this Certlfcateef Exemption,you NEWRESIDENDAL PLMB. SQFr. Remi tic
should becomn subjca to the Workers'Comparuatlon Provisionsof the Labor TOTAL:
0 Code,you must forthwith comply with such Provisions orthls permit shall he B
j deemed rooked. _�
CL CONSTRUCTION LENDING AGENCY SEI •E L
Ihercbyafflrmthat them bacorstmctlon lending agency for the peaorm ELE R E
Z anreofthe work for which this permit is Issued(See.3097,Civ.CO TOTAL:
U Q Landers Name PLUMB F E
LL F Lender's Address' QTY. MECHANICAL PERMIT KrEEMECL 'E �--
U I mrtifythat l have readthls application and statethaHheabove In formationC• W ucormd.Iagrceto comply with aR sty and countyardinanonandstate laws PERMIT ISSUANCE FEES
}
Q. relating to building contrudlon,and hereby authorize representatives of this F U) city toenter upon the abovcmenuored property for Inspection purposes, ALTFRORADDTOMECH.
(We)agree to save,Indemnify an d keep harmless the City of Cupertino ate ReCel t#
V against habilitks,Hdgments,costs and expenses which nmy In any way same AIR HANDLING UNIT(TO 10,ODO CFM) I SUBTOTAL:
against said City in consequence of the granting o hispemnit.
L AIRHANDLINGIIMT(OVERIO,ODOCFM) CONSTRUCTI NTAX
r
Signature of Appll t/Centracter Date EXFLIUS'r I IOOD(W/DUCT) CONSTRUCTI NTAX PAID: w /F
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant orfuNre building occupant stare or handle hazardous HEATING UNIT(TO IOO,ODO BTU) Date
mRece _
aterial n defined by the Cupertino Municipal Code,Chapter 91$and the -
Fkalth and Safety Cade Stolon 25537(a)7 HEATING UNIT(OVER 100,000 BTU) T
❑ Yn No
Will the applicant IQ.Wilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous atrwnbMrunteas defined bythe Bay Area Air rN A a
• a fly Management District? BOILER-COMP OFR'OR 100,D00 RTU)
4 Yes n No
have read the has oua materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BN)
the Q���
CzlifomlaH.Ith&&fmy Code,Sediors25505,25533and25530. i C�
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.ET �s I
neponslbll fly to not fly the occupant of the requirements which must be mart ` `',. `, ,w r+
prior to issuance of a Certificate of Oav parry. — (✓ City Vt.
Q/W�rCn
Owner or aulhadud agent Date �=J •ISSUED BY
OFFICE COPY