23395 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMOT NO.
Building Address: 4,lU LQ a 23395
'L'�j U90 P, Y
wnere ame: A one: APP=r5R3UffM7rAL
CITY OF CUPERTINO-BUILDING DIVISION -
nr,Name:/ q/ Lie.No: APPLICATION if PERMIT
BUILDINGELECTWCALMUMBING-MECHAMCAL CATEGORY CONTROLN
Anehinct/Vigneer. Lic.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: �T / PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION �a
I hereby affirm that l am licensed under provisions of Chapter 9(commenc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwith Section7000)ol Dlvislon3 ofthe BuslnessandPmfe�si neCode,and my
license is in fuI f and d(ect aI a /- /(//� PANELS elTy'F�'
Lacenu Cha Llcp [f ( y '�
to 3ontract 2d1
,CRC hall be s DECLARATION SQ.FT.FLOOR AREA S/SQ.FT.
[B u *W AMS
nO O I understand my plans shall be used v public records.
' b of Licensed Pmfesslavl Sir, ELECTRI L O�l
C� OWNER-BUILDER DECLARATION SPECIALCIR / l/
�o.,, z, Ihereby afRrmthat l am exempt fromthe Contractors License law for the S�
F 2 t- following reason.(Section 7(DIS,Bualne�and Pmfessione Code:Any city or gyp,M LE INST. ® ' I\B
countywhichrequbnapermittommtmmilter,lmpmve,demollsh,orrcpair tl
.Qa anystmd mpd WibL amc aL requr theappeontforsuNper tto POWER DEVs
99 a U Be a signed statement that he b licensed pursuant to the piewislona of the
Ow Contractor's License Law 0Dapter9(commencingwith Section 7000)of DWI- SWIMMING POOL ELECTRIC TE R
30�^ sion3ofthe Businessand Profemlom Cod0orthat hebemmptiberefromand 2 y VALUATION
Fe@ the basis for the alleged exemption. My ,violation of Section 70115 by any UTLETSSWITCIIF_SH%TURES A d _Z `� W
❑,�0 appBmntforapermltwbjeRtheappecanttoadvilperoltyofna=mtlun Q f-
a $ five hundreddollars($SM. NEW RESIDENTIAL ELECIR
I,as owner of the SQFT. STORIES TYPE CONSTRUCTION
..�, ❑ property,or my employers with wages as thele wk
rompematiKBusiness
uldess the
andweak,and the,Code:Theure,Is
intended or Ltd.L w
p vor
ie(See 7014,Bus"^•and Profevlow Code:The Contractols Linsue law
(2j $ don not apply to an owner of property who builds or Improves thereon and OCC.GROUP RLS.UNITS
whodonsuchworkhm lfothrough Msownemployees,providedthatauch
improvements are not intended oroffemd for sale.If,however,the W ilding er TO
Improvement u sold within oneyearofcomplation,the owner-butIderw111 have
U),J(urden of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOODWNE APN
L_1 L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
ML
contractors to mmtmd the project(Sec.7014 Business and Professlore Code:
com
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon, and who contracts for such projects with• FEE SUMMARY
co ari hceneed pursuant to the Contractor's License Law. BACK FLAW PROTECT.DEVICE
L j I am exempt under Sec. B k P C for this reasonOUTSIDEFTFS
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RICEITM
WORK MAN COMPENSATION DECLARATION .���I.�.I.�IP SCHOOL TAX Y_ N_
F-11 hereby affirm that I have a a camficedifiate of coraco to self-loom,ora RECEIPT N
certificate ofWorkeri Cooperuaionlmurance m a certified copythereof(Sec. GAS EA.SYSTEM-11NCA OUTLETS PARK FEE Y N
3800,lab C.) RECEIPT If
a GAS EA.SYSTEM-OVER 4(EA)
om any BUILDING DIV FEES
c
Cedified ropy Is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
❑Cediied copy Isfiled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SAMTARV-STORM G.2001T. D e ReceI t#
(This section need not be complded if the permit is for one hundred dollars
(510B)orless3 WATERIIFATERW/VENT/ELECTR ER E _ N_
I certify,that In the performance of the work for which this permit Is Issued,
1 shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
W.,lods'Compensation Laws of California.Date P
O Z Applicant NEW RESIDENTIAL PCMB. SQF'L Date Recei t#
Z O NOTICE TO APPLICANT-.If,after making t his Certificate of Laemptlon,you
Hshwld become subject to con workers'Compenaatlon provisions of the labor TOTAL:
� v1 Code,you must forthwith comply with such provisions or this perrut shall be BUIL f2
W ] deemedrevoked.
CONSTRUCTION LENDING AGENCY sa S I
a lherebyaflrm that there is a construction lending agency for the perform- T E T
7Z ante ofthe workforwhichthb permit la Issued(See 30W,CIv.C.) P B FEE
V O Lender's Na me
LL r Lendcr'a Addrcaa QTY. MECHANICAL PERMIT FEE M HANICAL IE
O W I certBythatDuve readthisappliatlonand statethat theabove information
V correct.I agree to comply with all city and county ordinances and state laws PERMITISSUANCE FEES PAID:
>. IL relating to building construction,and herebyauthorize representatwea0fthb
H NZ city to enter upon the above.mendorrd property for inspection purposes. ALTER ORADD7O MECH. Date Rxeipt#
(We)agree to save,indemnify an d keep harmlem the City of Cu ped Ino
V against liabilities,I.dg, rat,deasand expenxe which may lnanywa a AIR HANDLING UNIT(TO 10,000 CFM) UBTOTAL:
egaWt City in xiquo the ting of this permit.
I eeAIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTI NTAX
i a re0 pp ant ontrador FXIIAUSTHOOD(W/DUCT) CONTAX PAID:
HAZARDOUS MATE UR at
IALSOISCLOS
Will the apphant orfuture building occupant store or handle hazardous HEATING UNIT(TO I00,000 B= Date Recel t#
material as defined by the Cupertino Municipal Cede,Chapter 9.12,and the
Health and Safety Code Section 25532(2)2 HEATING UNIT(OVER 100,000 BTU, TO
❑ Yea N No
Willtheapplinnt or futumbuildingoccnpantusecquipment ordevices VEMILATIONFAN(SINGLERESID) ISSUA ATE
which emit hazardous air contaminants as defined by the Bay Area Air P A I
Quality Management District? BOILER-COMP 0H POR 100,"BTU)
4 Ye, n No
have read the haw us materials rcquircmnnlsunder Chapter 6.95 of BOILER-COMP(OVER 100,OW BTU) LIAR 12 199
the California Health&Safety Code,Section 25505,25S33 and 25534. 1
understand that if the building don not currently have a tenant that it Is my NEWRESIDEMIALMECH. SQ.£T
raFeasibility to notify the occupant of the requirements which=at W met
prior to issuance ofa Certificate olOmpancy. C((ICYY..Uh CUPttisnlu(P
Owner or authorived agent Date ISBUED gy;y{,lCS'r
TOTAL:
OFFICE COPY