23639 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Build Ing Project Identification PERMIT NO.
Building Address: 23639
I e s 0, � ��
wnera ame: one: p
Q,e_ CITY OF CUPERTINO-BUILDIN VISION T"a
Contrail sName: Lie.Noe APPLICATION 1 MIT J
. d 14 BUILDINGELECTRICAL PLUMBI -MECHANICAL CATEGORY CONTROL p
Arc l/Engineer. Lk.No:
nee QTY ELE RIC RMIT FEE BUILDING PERMIT INFO
Add.,. PERh11T IS5U NC •: ❑ ❑
LICF.NSF.D CONTRACTOR'S DECLARATION '
I hereby affirm that l am licensed under provisions of Chapter9(rommene, VPIMC#ZSIDENI1t4 V JOB DESCRIPTION
Incense iSeMon7000)of Di effect tlhe Budnessand PmtesslonsCode,and my
license b e full rte and effect.
Licen Ia Lk.p
Date Contractor 2M :Z k200AWS
ARCHITECT'S DECLARATION 101-1000 PS
µQ!NZpC I understand my plana shall be used as public records. VER1 IVV SQ.FI.FLOOR AREA $/SQFr.
E 0 U Licensed Professional SIGNS E L
fn OWNER-BUILDER DECLARATION SPECIAL CULT ISC
Zf, Iherebyaflren that l am exempt from/he Contractor's License law for the
following reason.(Section 70'31.5,Business and Professors Code:Any city or
O TE.IP.MEFES RPOLE INST.
P4 countywhlchrequnes a permit tomnstmct,alter,improve,dennllsh,orrepalr -
$$$ anydmclure prior to its issuance,also requires the applicant for such Parrott to POWER CES
Eke a signed statement that he is licensed pursuant to the provisions of the
3 Ow�+ Contractor's License Law(Chapter 9(commencing with Section 7000)of Dlvl- SWAIMING POOL ELECTRIC pon3 otthe Buslneeaand I'mdessimaCede)orthat he k exempt therefromand VALUATIOU"e
the basisfor the alleged exemption. Any violation of Section 70115 by any
O applicant fon permVILEISSWI7CIiESHK'
it subjects the applkant to a civil penalty of net room than
$ five hundred delta.(5500). NEWRESIDENTIALELECTR \
[r ❑I,as owner of the property,or my employees with wages u their sok STORIES TYPE CONSIRIICTIDN
tt M compensation,will do the work and the structure is not intended or offered for
5 sale(Sec.7074,Business and Professions Code:The Contractors License Law
[� $ does not apply to an owner of property who build,or Improvers lhecer,and OCC.CROUP RFS.UNITSC. who does such work hlmselforlhrough his own employees,provided that such
improvements are not Intended or offered for sale.If,however,the building or T
Improvementlssoldwilhlnomyearofmmpletb theowner-bullderwlllhave
theburdeno(provogthathe did not bpurpose of or improve for purpof oak.). QTY, PLUMBING PERMIT FEE
uu I,as owner of the property,am exclusively contracting with Beamed FLOOD ZDNI APN
PERMITISl1ANCE
contractors to construct the project(Sm 7044,Bushes and Pro(evku Code:
The Contractor'a License law does not apply to an owner of property who, ALTER-DRAIN&VENT-WATER(EA)
Wild.or Improve thereon,and who contracts for such p(u)ects with a FEE SUMMARY
�gBttactor(s)licend Inrmanttothe Cantracke.License Law. BACK FLOW PROTECT.DEVICE
LJ 1 am exempt under Sec B&P C for this mason
•
DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y N QnMcn-lu FEES
Owner Date RECD If
WORKMAN COMPENSATION DECLARATION FIXNRES PER TRAP SCHOOL FAX Y N_
01 hereby,(firm that I have a certalcom of consent to adit Inure,or RECEIPT e
certl(kate o(Workeri Compensalonlvunnce oramrtlfkd mpythereof(Sec. CAS F.A.SYS[TM.1 INCA OUTLETS PARK FEE Y N
Poli Lb C.'') `pp''
1'otry N DING DI M
Com an i min On
CAS EA.SYS1EM-OVER4 MA) BCK FEE
to FEES
�ccrtined copylshereby forelhea. 1 CREASE/I PL NCHECK PL•E
TVI
Certified ropy k filed with the city Inspection division.
Y' CERTIFICATE OF rXMPTION FROM WORKERS' GREASE PAID
COMPENSATION INSURANCE SEWER-SANITARYDate Recoi t# .
(this m Area.ion need net he completed if the permit ls(�rone hundred dollars ''T
0100)orlesJ WATER 1.IpglLYiii*UINT/ EN RGY FEE Y N
Icertlfy that Nth,Performance of the work lorwNcM1 this permit is lased,
I shall not employ any person In any runner m to hccome oubfectw the WATER SYSTEM/TREATING
Wm1uo Compeniation Laweot Calif am a ID
Z Z Applicant Date Recei t#
Z O NOTICETOAPPLICANT: er making this CertiOale of Exemptlan,you NEW RESIDENTIAL PENCIL
Fshould becomosubk eWorken'Compensation provbions ofthe Labor TOTAL:
CC W Code,you rrwd(orthwlth mmple with suchprovlaons arthls pertnit shall be
W e
> deomd revoked. SEISMIC FEE
BUILDING FEE
CL CONSTRUCTION LENDING AC CY
Ihercbyaeme whicerelse constmctlm agency for the perform TOTAL: ELECTRIC FEE
Z aroder.the work for which this perm) ed(Sec.3097,CIv,CJ
U O ndersName PLUMBING FEE
LLF" Lender'sAdderse QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Iced lfy that l have mad this application and pate that the above Information
Is correct.I agree to comply with all city a rad county ordinances and pate laws PFRMITISSUANCE FEES PAID:
r_arelating to building mestuction,and hereby authorize representatives of this
F-. N city to enter a Pon the above-mentioned property for bapecton purposes. ALTFRORADDTOMECH.
Z (We)agree to save,Indemnify an d keep harMess the City of a ped too Date Receipt#
V ago tut liabilities,Pdgments,ends and expenses which may in any way acme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agaiut said City in consequence of the granting of this pea
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signentube of ABorst/Contractor Date _ EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occvpantdom or handle hazardous HFA TING UNIT(TO 100,000 BTU) Date ReCCi t#
material as defined by the Cupertino Municipal Code,Chapter9.IZ and the
Health and Safety Code Section 75532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
Fly. , ON.
Will the applicant orfuture bulldingercvpant use equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DAVE
which emit hazardous air cortamlunb as donned by the Bay Area Air
ality Management District? BOILER-COMP OHP OR 100,OM BTI)
Y YesNo
havcmad Health
a a�malde,S mqulremenlsurd and 25534.
of BOLFR-COMP(OVEt 100,000 BTU) PAID
' p�
theCalifornia EL if to building
Cade,Seccoructly have
a tenant,andthat I Po {J
undentandthatn tify the uccgpms not a rentlyhants whichthat It out NEW RESIDFN77AL MECH. SQ.Ff
rapouibllity to notify the ocmpant of the requlrementswhkh must 6e me[ ��� ��
prior to Lssuanm of a Certificate of Om Fancy.
Owner or authorized agent Data Iz t I '/
' TOTAL: I fly,
IISSUED BY:
OFFICE COPY