23315 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: I
' 05n - a -3 o�-s— 23315
-1 APPLICATION SUBMITTAL
Nr= �e�0.� �LfF Wad. 37Z CITY OFCUPERTINO-BUILDING DIVISION —Cl
Contractors Nam/soaI.a���aa� APPLICATION / PERMIT —�
s3L1(JU�L_1'{- BUfLDINGELECTRICALFLUMBINGMECHAMCAL CATEGORY CONTROL11
re Breit . ginner. Lk.No: 6
Qv ELECTRIC PERMIT FEE BUILDING PERMIT INFO
A d,175s PERMITISSUANCE 1-250-
LI ENSFDCONTR DECLARATION
I hereby affirm that l am licensed under provisions of Chapter9(mmmenc- APPLIANCESRESIDENIAL J DFSCRII ON
lnense 1,1.to 000)of Dlvlslon3o(theBudneuand ProfeWone Code,and my ��
license Is ink M. PANELS
License Class �Lk.N _
Date ContndoUP TO 200AM25ROoM P# p 1 T olv
--�ARCHITECT'S DECLARATION 201-1000 AMPS
q�q�uu
9
0 77 l understand my plans shall be used u public records. OVER 1"AMPS SQ.Fr.FLOOR AREA I/SQ.Fr. r•/
S (I Licensed PmfemWrul SIGNS ELECTRICAL jl
SPEC7:9-,
�[3 LI7 �2. 3
I<n6!y� OWNER•BUILDER DECLARATION IALCIRCUIT/MISC •`Y
Z I hembya(flnnthat l am exempt fromthe Contractor's License law for the I
q following r (Sectionro
son.(Seon 7031.5,Business and Pretenders Code:An ci r
w, mudywhich requires a permit w mrestruct,alter,Improve,demolish,orrepalr 7FMP.METER OR POLE IN
�7 any strudure prior to 3b lssuancgaW requirca theappHnnt for such permit to ^
rY1 file a signed statement that he licensed pursuant to the provisions of the POWER DEVICES
k R
SOSOu, Contractor's License Law(Chapter9(commencing with Section 7000)of Divi. a
SWEs1MINC POOL E7.E
don of the Business and Professlons Code)orthat he t exempt therefrom and CTRIC VALUATION
6 the beans for the alleged exemption. Any violation of Section 7031.5 by any Idn
OUTLETSSWITCHE&FIXTURES
It untforapears(subjectathe applicant too civil penakydred nnrcthe l/aN
Bffl, red dolWn NEWRISIDFMIALELECIR I
FI'(AS00). ,
e as owner of the property,or my employees with wages as their sok RIES TYPECONSTRUCTION
compneatlon,will do the work,and the structure(net intended or offered for
O sale(Sec.7014,lhothe u and Professions Code:The Contractor's License Law
3$ does not apply to an owner of property who builds or improve thereon,and OCC.CROUP RIS.UNITS
doesuch work himself orthrough hisown employee,provided that such
improvement are not Intended proffered forsaee.14 however thebullding or TOTAL:
Improvement(sold withlnomyearofcompletiorytheowner-builderw171 have a
tfunien olproving that Mdid not build or improve for purpose of sale.), QTy, PLUMBING PERMIT FEE FLOOD ZONE APN
��,,j L as owner of the property,am exclusively contracting with licensed PERMITLSSUANCE '
rontradore to coostrud the project(Sec.7044,Buslness and Prefesdo.Code:
The Contractor's License Law don not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or improve thereon,and who contracts for such p6ojedes with a
corts)licensed pursuant to the Contractor',License Law. FEE SUMMARY
tram exempt under Sec. B& P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N_
• Owner Date
WORKMAN COMPENSATION DECLARATION FDaURESPERTRAP O SCHOOL TAX Y N
❑1 hereby affirm that I have a Tmucate of caused to opytheurc,ora D RECEPTa
3800,Late of Worken'Comperaatlonlnsurance oracertl(led ropy thereof like. GAS EA,SYSTEM-1 INC4 OUTLETS PARK FEE Y N
Pol3800,lab C.)
Com an GAS FA.SYSTEM-0VERd(FA) RECFR'TN
Y BUILDING DIVISION FRES
Certified copy t herebyfurnishedthe cid. GREASE/INDUMRL WASTE IN'T'ERCEPTOR PLANCHECK FEE
filled ropy t(fled with/he city inspection divisors. ♦�,.,`
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASE TRAP PAID
aeCOMPENSATION INSURANCE Date Recei t# y �'
(Thlactlon need red be
COMPENSATION
permitt(orone M1undred dollen SEWER-SANITARY-STORM EA.200FI'.
(f100)mfy that
WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I certify thattthe penes unceofthework so as to
permitbecome
la trued, —
I shale not employ any person N any manner so u to become subject to the WATER SYSTEM/TREATING
Workeri Compeneatlon s lawof Gll(omla. Date pAlp
0 Z Applicant
Z O NOTICETOAPPLICANT:If,after making this Certificate ofExemption,you NEW RESIDFNTIALPLMB. SQ Date Recei t#
should become subject Io~ the Workrs
e 'Comperuatio,provisions of the Labor TOTAL:W Cade,you=at comply with such peovtlone or this permit shall be L
> deemed revoked. ••
CLC CONSTRUCTION LENDING AGENCY SEISMIC FEE
—
Iherebya!(Irm that there t a construction lendlegagency for the perform TOT 7• ELECTRIC FEE' 6_
7 Z anceof the work!ar which this permit t tesued(Sec.3097,Civ..C3 ° 3TL)
V O Lender.Name PLUMBING PEE _
LL f lenders Addreu QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertlfythatlhavereadthkappliudonand Aatethattheabovelnformation
IL tmrrcet.Iagreeto complywlthall cityand manly ordinances elate laws PERMIT ISSUANCE .Q FEES PAID:
} N relatingtobullding construction,and hereby authorise representatives oftht
H Z city to enter upon the above•menlloned property for Inspection purposes. ALTERORADDTOMECH.
(We)agree to ave,Indemnify an d keep harmless the City of Cupertino Date Receipt#
V
against liabilities,judgments,costs and expenses which nay In any wayacaue AIR HANDLING UNIT CEO 10,000 CFM) SUBTOTAL•
against said City In consequence of the granting of this permit.
AIR HANDLING UNIT(OVER I0,00oGM) CONSTRUCTION TAX
Signewre of Applicant/Contractor DateIXHAUSTHOOD(W/DUCT) 6 r CONSTRUCTION TAX PAID:
HAZAR DODS MATERIALS DISCLOSURE
Wllltheappllor ortown bulldingompant storeor handle hazardous HFATINGUNIT(T0100,000BTU) Date Recci t#
material as deeded by the Cupertino Municipal Code,Chapter 9.12..and the
Iiealth and SafetyCade S ce 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
F-1Y. o
Wllltheappllcent or uwrcbuilding occupant use equipment ordevkca VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous ab contanons Me as defined by the Bay Arca Air
4vallty Management muter BOEER-COMP(3111'OR 100,007 BTU) PAID A I D
Yee o Ir P9 Y N
have read the M1aza ousmatedak requirements under Chapter 6.95 of BOILER-COMP(OVEI 100,000 BTI)
the Callfomk Health&Safety Cade,Sections 25505,25533 and 25534.1 ���
understand that lfthe building don not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FI' L' �(��
responsibility to notify the occupant ofthe requirement which must be met 5 s7
rlor to lluanc rtili sol Ocmpancy
��y�Z G�7Y Ut�urcn n
Owncrorauthorizcd Date ISSUED BY:
TOTAL:
OFFICE COPY