23912 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pon act Identification PERMIT NO.
Building Address; 59.3 � , 23912
nen aces: one: -
astato-OJT,. CITY OF CUPERTINO-BUILDING DIVISION ("
c.Mnctnr@Name: Lie.N. APPLICATION I PERMIT v� L
BUILDING-ELFCTRICALPLUMBING-MECHANICAL CATEGORY CONTROLp
Architect/Engineer. Lk.No:
QTY ELECTRIC PERM BUILDING PERMIT INFO
Addms
PERhRTISSUANCE �
LICENSED CONTR under provisions
Ihereby hSmUon7Olhatlamlicensed 9.3.fh.Oug v ndPromionar9(rommenc API'LiANCESRE9 E L OESC ON
Ii.r.I Sectfon force of d affedn3 ofthe Budnessand Pro(esslonaCode,and m
license la In full force and disci. PANELS
cenx ClassLi,.
D
Date Contra Corto
ARCHITECTS DECLARATION 1 PS
pQ?esO z I understand my plans @hall be used u public records. V I"AM SQ.Fr.FLOORAREAE/SQ,Fr.
E OLicensed Professional GNS EC CL
I� 7 7 L 14,
OWNER-BUILDER I-nDECLARATION E1 AL
(hereby af(lrmthatiam exemptfromthe ContnctorL Llcenx lawfor the SPECICIRCT/MISC
following reason,(Section 70315,Business and Professions Code:Any city or
O:4
ti� ]'FMP.ME[TR OR INSf.4g� cauntywhich require@@ permit to ronslmct,aller,lmprove,demolish,orrepalr
OONanystwu mpriortoiGLL anceaLwmquimtheappllantforsuchper tto POWER DEV]
�d U file a signed statement that he la licensed pursuant to the provisions of the
g� Conlracim'e License Law(Chapter 9(commencing with Section 7000)of Divi- JJNIMMING POOL ELECTRIC
sion 3 ofthe Business and Professions Code)orthat he fit exempt lherefromand VALUATION
0 the basis for the alleged exemption. Any violation of Section 7031.5 by any UTLETSSfMTCHFSRJCfURES
applicant fora permit subjects the applicant to a civil pemity of na mnrethen
Dv. undreddollars(3500). SQ.FT, SIDRIGS TYPE CONSTRUCTION
a@ owner of the property,or my employees with wages as their wIs NEW RESIDENTIAL ELECIR
co tpereation,will do the work and the structure is not intended or offered for
,J O sa !$ee.7014,Busmen.and Professions Code:The Contractors License Law
f'j3$ does not apply to an owner of property who builds or Improves thereon,and OCC GROUP RES UNITS
WW whodmssuchwork himself or though provided employees,prlded that such
Improverrents are not Intended oroffered forsale.If,however thebullding a
Improvement
baeld withlnoneyearofcompletlor theowner-budderwlll have
tt6,den ofproving that he did not build or improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
Lf L as owner of the property,am exclusively rami a ting with licensed PERMITISSUANCE
ri
contractors to construct the project(Sec.7D66,Business and Professions Code: I1
The Contn Lora License Law don not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
hudds or Improves thereon,and who rontnm for such projects with
cglRfactor(s)Ilanxd pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ Ism
exempt under Sec. 0&P C for this te.an nnR
I-fo ITSI 09 FEES
DRAINSFLDOR p, .99ND.IN, r. ANIA N_
Owner Date u RpLEBrpp
WORKMAN COMPENSATION DECLARATION 1(b Y N
❑I hereby affirm that I have•certlRate of consentamAift d epytharo,(Sa FIX7URF'PER 3 RFLl7I'T M
certlRate of Workers'Compeoatlon Insurance ora certified opythereof(Sec' CAS EA.SYSTEM.IINC. OUTLETS - PA N_
3800,lab Q
Policy If JECEIFT p
CAS EA.SYSTEM ER4(EA)
C
�om any n•-t_ BUIL INC DIVISION FEES
Cenilied copy is hereby furnished. CREASE/INDUSTR WASTE INTERCEPTOR ----- -PLA CHECK �EE
Cert11(ed ropy is pled with the city Cty inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CRFASETRAP PAID 7
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA MOPEDRte RCCCI tb "BOO
(ThlsxClon need not be compined If the permit is ionone hundred dollarsP
(9100/orW,ATfR1 EATER 4,V/VFNTIELECTR ENERGY FEE Y N
(certiffyy that In the performanceo(ehework(mrwhkh this permll b issued, J_40C
I shall not employ any person In any manner are as to became subject to the WATER SYSTEM/TREATING ` 40
Workers'Compensation laws of Callfomla.Date PAID
OApplicant
Z 0 NOTICE TO APPLICANT.It,after making this Cert0late of Exemption,you NEW RESIDFN'DALPLMB. SQFF. Date
should become subject to the Workers'Compeoat Ion provisions of the Labor T
NCC
Code,you mu at forthwith comply with such powscona orlhis permit shall be �� `e
W ) deemed revoked. '
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL G Iherebyaffirm ohat there isaamtruClon lending agency forth.perform- ELECTRIC FEE
3 Z anceoftheworklarwhichthis pe rmltlaluued(See.3097,Civ,C)
V0 Lenders Name PLUMBING FEE
LL F Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW tariilythatl have read theapp0oti...od vatethattheabove Information
1 Is rorrect.l agree to comply with all city and county ordinances and slate laws PERMITLSSUANCE FEES PAID:
} relating to building construction,and hereby authorize representatives ofthis
N Cly to enter u pon the abovecrenlloned property for Inspection pu rposes. ALTLRORADDTOMECH. lop
Z (We)agree to save,Indemnify an d keep harmless the City of Cu Earthen Date Regie( tN
O ag.itatliabhilt�dgmenI'cote and expense@ which may in any way accrue AIR HANDLING UNIT(TO 10,000 CPM) SUBTOTAL:
agalMteald Ci cons.7anceoflhe g(arSing of thh pertnit.
AIR HANDLING UNIT(OVER IO,ODOCr CONSTRUCTION TAX
SInature of Appllrant/Co actor Data DCHAUST HOOD(WI DUCT) CONSTRUCTION TAX PAID:
HAZA66OUS MATERIALS DISCLOSURE
Will the applicant or future building ontrpantstma,or handle hazardous HEATING UNIT(TO 100,000 ITIA Date Rec ' t
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the --
Ilaith and Safety Code Section 75532(a)I HEATING UNIT(OVER 100,0110 BTU( T
OYes No
Will theappllam or Lure building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit has rdous air contaminants as defined by the Day Area Air
1. Quality Management District? BOILER-COMP OTB'OR 100,000 BTU)
�I Yes No
a ave read the hazy ous materials requ immenb D
under Cha pier 6.95 of BOILER-COMP 100,000 BTU), � � �
the Ca llfomia Flealth&Safety Code,Sections 75505,75513 and 25534.I N'
understand that i f the be ilding does not currently have a tenant that it is my NEW RESIDENTIAL MECFI. SQ.Fr
mpooibDltyto of aCeheicte of Ocfparcy.requirements which must be met SEA Q ,r�
prior to issuance ricey thec expo tof the req 1�� 5[.I .s
Owner or authorized agent Date ISSUED By,
OFFICE COPY
i