23440 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: 23440
/L9/L-)/ 14/0Z-6 60P o
s rat: one: A A
YoS-�,SS— O CITY OF CUPERTINO-BUILDING DIVISION r
Contractors Name: Lia.N. APPLICATION /PERMIT
A�rch�itect�/�Enginee Lie No: BMLDINC-ELECTRICAL-PLUMBINGMECHAMCAL CATEGORY CON'&CIO'.T
M `6 I, 0 C cl7 5 QTY ELECTRICP lE BUILDING PERMIT INFO a�
Address G(/ SAu.6-'WE• 2EN 0PLUMB
PERMITISSUANCE ❑ ❑
1 F. ED O TRACTOR'S D I.A RATIONin
Iherebyaffirmthatlam Bcensed under providoesof Chapter9(mmmenc- ANUANCESiRE, DE L OBDESCRB'TION
Ingwith Section7000)ofDiWslon3ofthe Buenessand PmfesslonsCode,and my
license Is in full fora and effect. PA
Licence Class L(c.N
Date Contractor
ARCHITECTS DECLARATION 1 A'MES
W 7 I understand my plans shall be,used.public recesed. ER 1000 /��/��jQ2.FT.a R AREA $/SQ.Fr.
K�tY�j
Licensed Professional SIGNS EIEC INV JI
a<w OWNER-BUILDER DECLARATION 6@)
In Ei SPECIAL CIRC T/MISC
I hcreb afRrtnthatlam exem from the Contractor's License law(a the R
�O o� following reason.(Section 71315,Business and Pmfre,lons Code:Any dry or TEMP.METER OR POLE INST. �t E , a
FSa� counrywhkh requiresapermittocanstmct,alter improve,demolLah,arrepair
�, anystacturc pdortolV bsuan<e,aborequlrcatheapplicant(orsuch V perMtto (-OWER DEVICES Z file a signed statement that he b provisions licensed pursuant to the pvisns of the DATE
Contractors License Law(Chapter 9(cood
m ,nn ith Section 7")of Levi-
SWIMMING POOL ELECTRIC
30rn sion3 ofthe Business and ProfessonsCode)orthat he Lsx
em lherefmmand ATION
the basis for the alleged exemption. Any violation of Section 71315 by any OUTLETSSWITCHESFDTURFS O 1
6i applicant fora permit subjects the applicant to a civil penalty of not more than
P. five hundred dollars($5001. NEW RESIDENTIAL ELECTR SQk . STORIES TYPECONSTRUCTION
�n L as owner of the property,or my employees with wages as their sole
lien ttion,willdothe work,and thestruchom Is not Intended or offered for
$ O sole(Sec.7614,Busiesand Profeadera Code The Contractors License Law
$$ does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RFS UNITS
doessueh work himself or through hisown employees,provided that such
Improvements are not Intended mattered forsale:If,however,the building or TO
Improvement esold within oneyearofcompletion,theowner- ilderwill have
tM1 rdenof proving that he did not build or improve for purpose ofszle.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
�1,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractor's License Law does not apply to an owner a property who ALTER-DRAIN&VEM-WATER(EA)
Wilda or Improvers thereon,and who contracts for such ptolects with a
CgCtt ctr(s)hanxd pursuct
ant to the Contraor's LI...Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
IJ 1 am exe t under B& P C for this reason
Owne Data DRAINS FLOOR ROOF,AREA,COND. SANITARY RECEIPT If �
ORKMANCO ENSATION DEC" A ION FIXTURES PER TRAP SCHOOLTAK Y N_
1 hereby afftrm that 1 have a anl0ate of concent to selFinwrea a RECQPT N
<ertl care o(Workers Compensation Wurana ora artifled copythereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N_
3800,Lab CJ RECER'T N
F/0Policy N GAS EA.SYSTEM-OVER 4(EA)
Com any BUILDING DIVISION FEE$
EyCertiBed copy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCIIECK FEE12AM
[3Crrofied copy V filed with the city inspection division. Mt CIW
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID I
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date Receipt#
(This section need nut be completed lithe permit b form a hundred dollars
($100)orless) wATFR FI&vrER w/vFNr/E.FOTR ENERGY FEE Y_ N_
1 certify that In the performance of the work forwhich this permit Is Issued,
1 shall not employ any person In any manner so as to become subject to the WATER SYSIFM/TREATING
Workers Compensation Lawsof California.Date PAID
O Z Applicant NEW RESIDENTIAL PL.MB. QFT. Dale Recei t#
Z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should became sub ed to the Worked'Compensation provisions of the Labor TOTAL:
N Code,you nwat forthwith comply with such provisions,or this permits hall be BUILDING E
Ir Ln
deemed revoked.
W _ CONSTRUCTION LENDING AGENCY SEISMIC FEE O
WCL Ihereby afOrmthat there is a construction lending agency for the perform, TOTAL, ELECTRIC FEE
M Z once of the work for which this permit Is coded(Sec.3097,Civ.C.)
U O Lender.Name PLUMBING FEE
LL F lenders Addreas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
L) Imr[Ifythatl have read thlsapplicatlonaM statethat theaboveinformation
O W bcanect.I agree tocomply with all cityand county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. N relating to building construction,and hereby authorize representatives ofthis
I.- Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,Indemnify an d keep harmless the City of CupeNoo Date Receipt#
U against liabilities,judgments,casts and expenses which may In any way amue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
againf said City In consequppp f the granting of this pe It.
��// AIR HANDLING UNIT(OVER IO,DOOCFM) CONSTRUCTION TAX
SI turcof Applicant/CContractor Date EXHAUST HOOD(W/DUC37 CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT CFO ICB,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the
I I Mth and Safety Cade Section 2553](.)1 HEATING UNIT(OVER 100,000 BTU) TOTAL.
n Yds I]No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which emit hazard...air cantand uuds as defined by the Bay Are.Aar
Quality Management District? BOILER-COMP OHP OR 100,IXp BTU P A Y D
4Yes No /Y
have read theM1aardouN materials rcgnircment.under Chapter 6.95 of BOIL�R.COMP(OVFR 1(D,0E0 BTU)
the California Health&Safety Code,Sections 25505,75533 and 25534. 1 Q
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECIL most e reedSAFE MAR 2 C� 199
responsibility to notify the occupant of the requirements which st btM
prior to Issuance of a Certificate of Occupancy.
Owner or authorized agent Dae TOTAL: ISSUED BY _
OFFICE COPY