23866 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification PERMIT NO.
Build Ing Address:
23866
el1ate ams: ccnn one; APPLICAll It,
�+�1 izom CITY OF CUPERTINO-BUILDING IVISION /a_ 'q]
• c artnraNameS �� APPLICATIODI I P IT b —1
BUILDING-ELECTRICAL pLUMBI -MECHANIC CATEGORY C
rchitent/Engincer. Lk.No:
TY ELECT TCP R IT FE BUILDING PERMITINFO
Address: SQ C PFRMITISSUA I\/I
LICENSED CONTRACTOR'S DECLARATION % 1:1 17 [T[hereby afRrenthat l am Remsed under provisions of Chapter 9(oammenc A VITAL JOB DESCRIPTION
Ingwlth Sedlon7000)of Dlvlsim3nfthe Busim.and Professlon.Code,andm
Lice. la inlCis fu effect ( �Q )— TWA L w�'�
Llcen Cls LIc.M
Date Corrector life-
ARCHITECTS DECLARATION ZMIODOAMPS
N'ZO x�
Iandent.ndmypl.., aUbeudaspc.
ubbcrds OVERIOW `.Q
AMPS SQ.FT.FLOOR AREA $/ .FL
tt Licensed Profmslowl SIGNSELECIRI
<6 OWNER-BUILDER DECLARATION
InaSPECLILCIRCUIT/
Zt, QJ
[hereby a(Brm tlarlam exempt from the Contractor's License Law for the
oo following reason.(Section 7031.5,Business and Professions Code:Any city or
TF7r1P.METEt OR POL INSf.
r cduntywhlch rcquimfapertNt to cowlruci,aller,lmprove,demoReh,arrepair
anystmd mpnortolbW ancgal mo qulrmrheappHmntforsuchpermirto POWE1D 1
'ryG file a signed statement that he Is Itemsed pursuant to the provolom of the
µ0� Co,lrscmrb License,IA.(Chapter 9(rommeneing with Section 7000)of DWI- SWIMNUN
L., .Ion3oftheBualnmsand Profm.lov Code)crthathelsexemprrhemfmmcnd r VALUATION �s•s/�,
O$ et the basis for the alleged exemption. Any violation of Section 7MIS by any I _`
applicant for a permit subjects the applicant to a civil penalty of nrome,han OU7LE.� 0 e
five hundred dollen(¢SW). 57OItlpS TYPE CONSTRUCTION
'9..' �1,as owner of the property,or my employees with wages as their sole NEW RESIDFMTAL ELECTR
$ compenaation,will do the work,and thesimeture is not intended or offered for does O dole(Sec appy to alnesa and f property Code:The Contractors Llceme Law
whonot suchpply oanownel orprough who nemWildorimprwmderith t and OCC.GROUP RES.UNITS
0.0. whodoementsa nota tends oraughhbowne.If,ho ee,provWedllding h
Improvementsarcnotintended earofco Torula,If,however, alder ill have TOTAL:
Improvement bsold wllhinoneyearofcompldloMthe owner-bulWerw111 have '
UAJIurdeu of proving that he did rat build or Improve fee purpose of uk.). CITY. PLUMBING PERMIT FEE
Lj I,as owner of the properly,am exclusively contracting with If...d 7.7.0'OD TONE APN
mntracron to constrod the project(See.70K Business and Professions Code: PERMIT ISSUANCE
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
build.or Improv"thereon,and who contracts for such p,)eds with
ca,,00.I.{actor(s)Untried pursuant to the Contradeam Llmnse Law. BACK FLOW PROTECT:DEVICE FEE SUMMARY
LJ I am exempt under See. 0 k P C for this reasonOUTSIDE I'EIZS
DRAINS-FLOOR ROOF,AREA,COND. SANITARY Y N
. Owner Dale RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOL TAX Y N
❑1 a emby affirm that I have ocertificateInsurance
c of consent to opythsurc,ora RECEIPT
Y
certificate C.) orkems'Comperaatlon Lauranceoracertlfkd mpythemof(Sec. GAS EA.SYSTEM-1 LICA OUTLETS PARK FE? Y N
3800, # C.)
Poll N RECEIGAS EA.SYSTEM-OVER DING TM
Com any BUILDING DI VISI FEf.S
edified copy is hereby filed
the ed.city
GREASE/INDUSTRL WASTE INTERCEPTOR PLANCI-IECK FEE
Certified copy is flied with the dty IrupMlon division.
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 20OFf Date RCCe) t#
RhlaeecUon need nd Mcompided Bthe permit Ia(orooa M1undred dollen
($100)cr len.) WATER HEATER W/VENT/ELFOTR ENERGY ' N
1 certify that In the perfomunceof the work forwhich this permit Is blued,
1 shall not employ any person In any manner so an to become subject to the WATER SYSTEM/TRGTING
Workers'Compensation laws of California. Date PAID
O Z Applicant to Recei t#
Z O N077CET0 APPLICANT-.If,akar making this Certlflare of&emplion,ycu NEW'RESIDENTIALPLMS. SQFT.
Neh.ld became subject to the Worker'Compensationpmvblona o(the Labor _ TOTAL:
C y Code,you=at forthwith comply with such provisions orthla pemit shallW E r
deemed revoked.
LU
C CONSTRUCTION LENDING AGENCY IC FEE
Iherebyafflrmthat there V a roratrudion lending agency for the perform- E •CTRICFE .
M 0 arm or the werkfor which this permit is Issued(SM 3097,Clv.C.) TOTAL: _
U Lenders N. PLUMBING -E
LL ~ IcndereAddress QTY. MECHANICAL PERMIT FEE MECHANI LFEE
OW Icertl(ythatl have read this application and statethatthe above Information
1 licerred.I agreeto comply with all city and countyordleanaaand stale laws PFRMHISSUANCE FEES PAID:
} N relating to building construction,and herebyauthorice representatives ofthis
H Z dtyto enrerupen theabove-man property forbapectlunpurposea. ALTEIRORADDTOMECH. Date RecCl t#
(We)agree to ,indemnify n d krep harMem the City of Cupertino P
agaimth im," g. to nd expenses which may In anywayamroe AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL'
against 1 Ity conseque f the granting of this permit.
7�9Z AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRU ON TAX
sl or pan onrr dor Date EXHAUSTHOOD(W/DUCT) CONSTRUC N TAX PAID:
H RD SMATERIALS DISCLOSURE
Will the applies, orfu buildingomupan4mrecrhaniteharardous HEATING UNIT OO I MORD BTU) Date RCC . t#
material as defined bytM upertino Municipal Code,Chapter 9.17,ancithe
I lealth and Safety Code Section 25S32(a)7 HEATING UNIT(OVER 110,000 BTU) OT
F1yesNo
Will the applicant ce turebulldingoccupantuseequlpmentordevlma VENTILATION PAN(SINGLE RESID) (S$I}py�L TE
which emit haeardous air contaminants as defined by the Bay Area Air C
Quatity Management D❑lstdd7 BOILER-CAMP OITPOR 100,010 BTU) ��
• , Yes d No /
have mad the bora ous materials requirements underChapl.r 8.95 of BOILER-COMP(OVER 100,000 BTU) Yn
the California I lealth h Safety Code,Sectima 75505,5533 and 25534.I T
undemtandtharifthebuildingdomnolmmmllyhaveatenant,th.titlsmy NEW RESIDENTIAL MECH. 9QFT CIIYCh•CI, ��
responsibility to notify the occupant of the requirements which moat be mel Ur
pnor to Issuance of a CgtlRatc of Occupancy.
Owner or authorlmd agent Date
TOTAL: ISSUED BY:�-s/=i-a
�� OFFICE COPY