23420 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification zX 2 l PFILWTNO.23420
Building Address: O
_ 01-i, w
nor• one: A
G CITY OF CUPERTINO-BUILDING DIVISIONj0_LZ
Ali rad ' Name: J LNo- APPLICATION /PERMIT X
pr Itcd/P BUILDINC-ELDE IRICALPLUMBING HAMCAL CAITiGORY COIR 2
- w QrY ELECTRIC PE FEE BUILDING PERMIT INFOO If
Address: ` A%JU PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed u oder provisions of Cha pier 9(commute APPLIANC L JOB DESCRITION
ingwlth Secllon7000)of Dlvislon3 ofthe Buslnessand Professions Code,and my
license Is In�fpull force and effM. �e
Lice_/ 4LIc.X 1
Dat Contmdrr 20th
ARCHITECTS DECLARATION OV' 1000 AM SQ.FT.FLOOR AREA B/SQ.FT.
qqqNOLC Iundetstand my plata stall be used upubtle ceroids
U Licensed Professional SIGNS ELECTRI `�A Z��•
Ga OWNER-BUILDER DECLARATION SPECIAL CEiCUIT/MISC
L., , Ihereby of nnothat l am exempt fromthe Contractors License Lwforthe
�OF� following rcason.(Sdion 7031.5,Business and Professons Code:Any city or TEMP.METPRORPOLEINST.
rountywhkh rcquims a pertNt to comiwd,alteq Improve,demolleh,orrcpalr
anystmmm prkete,its conance,also requires theappllcant foreaeh permit to POWER DEVICES
s, 1 V file a signed statement that he b licensed pursuant to the provisions of the
O n Contmdorb License Law(Cha pler9(commencing with Section 7000)of Divi- gWIMSUNG POOL ELECTRIC
'30 som
l3 ofthe Business and Preafessioru Code)orthat hole exem therefromand 1
Q the basis for the alleged exemption. Any violation of Section VALUATION
7031.5 by any, ETSSWITCHESH%TURES �, O�'� �+
�$ applicant for a permit subjects the applicant to a civil penalty of not nmethan
0ve hundred dollars($SM. NEW RESIDENTIAL ELECTR SQ.FT. STORIES 7Y1'E CONSTRUCTION
I]1,as owner of the property,or my employees with wages as their sole
compensation,wRldothe work andthe structure is not intended or offered for 1
9 D
In(Sec.7044,Business,and Professions Code:The Comlrador'a Llmtue Law
don not apply to an owner ofproperty who Wilds or improves thereon,and (3S
�s^ who doessuchwork himself orthrough his own employee,provided that such U'✓� s� p y a••� a..�
Improvementsare not Intended proffered for sale.ILhowevegthebuildingor T V' E6•/ U EL• ��••(l
improvetrcnt bsold within oneyearofcompleton,the owner-bulW erwill have
tli,tsarden of proving that he did not Wild or improve for purpose of sale.). QTY, PLUMBING PERMITFEE pPN
L
j L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE E
eontraeUas to construct the projed(Sec.7054,Business and Profmoon Code:
The Contractors Llcerue Law don cot apply to an owner of property who
oves f
Wilds or Imprthereon, and who contracts for such p,,a"with a ALTER-DRAW&VENT.WATER(FN
licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
cLJI am exempt under Sec B &P C for this reasonOUTSIDE FEES
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY YY_ NRKEIPT X_
WORKMANCOMPFNSATIONDEC RATION FIXTURES PER TRAP '�la' SCHOOL TAX Y_ N_
❑1 here !firm that have a cert10 o t to self-insure,w a RECEIPT X
` certlficateof ken' penia n rRfleicepythereof(Sec. GAS EA.SYSTEM-I INCA OUTLETS PARK FEE Y N
3800,Lab C.) L —
RECEiPT X
Policy X GAS E.A.SYSTEM-OVER 4(FA) BUILDING DI VISION FEES
ri copy h GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
C Ifiv i copy b filed with th y hopection division. ^ C-7
� TQ`�
CERTIFICATEOFFXEMPTION FROM WORKERS' GREASETRAP P/p1 1 b V
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. 6 Remi t#
Uhlsaeciion need not be completed lithe permit b forone bund red dollars
(stro)mrlee�.) wATFRHEATu(w/vENT/ELEcrR ENERGY FEE Y_ N_
I certify that In the perfomunceof thework forwhlch this permit Is la ued, ..
I shall not employ any person in any rranrer so e to become subject to the WAT02 SYSTEM/TREATING
Workers Compenaationrawaol Callfomb.Date PAID
0Applicant Date Recei till
Z Z NOTICE TO MIPLICANT:If,after making t his Certificate of Exemption,you NEW RESIDENTIAL FILMS. �F7.
O should become subject to the Workers Compensation provbloet of the Labor TO A
C N Code,you=at forthwith comply with such provbmns or this permit shall be
BUILDING 'E
W ] deemed revoked. -
CONSTRUCTION LENDING AGENCY SEISMIC FEE 4.� _
d IherebyafOrm that thew Is a mnstrodlon lending agency for the perform, T ELECTRIC FE' ^s
M Z ante of the work for which this permit is Issued
(Sec.3097,Civ.C.)
Q2 Lcoders Name PLUMBINCHEIA
IL r Lendcr'a Addmsa QTY. MECHANICAL PERMIT FEE MECFEJi
U 1 wrilfy that l have read lhbapplicatlonanl statethat theabovelnformation F -$
O W Iscorred.I me to complywith all city and county ordinances and gate laws PFRMRISSUANCE
} U) re to bui gconswction,and hereby authoress representativesof thio
f. Z ty toent'ce sa ,in cmentlonedp rtyf pectionpurpmos. LTERORADDTOMECH. at ReceiptN
(We)agree l save,lode Ify a h m the City of Cupertino
V agakutllabiliti ,j dg ,rug chmaytnanywayamue AIR HANDLING UNIT(T010,OODCFM) SUBTOTAL:
agairulssid yinm uenc this permit UC ON TAX
AIR HANDLING UNIT(OVER 1 0,000CFM)
' rum fA pliant/C o Date EXHAUST HOOD(W/DUCT) NSTRUCTI NTAX PAID:
HAZARDOUSM ERIALSDISCLOSURE
I the applicant or tutu c to ing occupant store or handle hanrdous HEATING UNIT(TO I MODO BTU) Dateei t#
ereal as defined by the Cu Ino Municipal Cods,Chapter9.lZ and the
kallhand Sfcty Cade dion25532(a)2 HFATING UNIT(OVER 100,000 BTU) l TOLAR
❑Yes,
Will the applin orfuture building occupant use equipment or devices VENTILATION FAN CE
RESIU) D ISSUANCE DATE
which emit hatandous air
contaminants as defined by the Bay Area Air
Quality Management Didol BOILER-COMP(3HPOR 100,000 BTU)
Yas
d11 oo5mitorialSm ire tsundcr Chapter6.95cf BOILER-COMP(OVER 100,000 BTU)
the Califrmi Health&SfetyCode, ,25533 and 255M.1 y� W
undemmndt tifthele Ing a have ten ant that itis y NEIN RESIDENTIAL MECH. SQ.FT. r U'
responsibilit to net a umcmentswhich must be met
priortoiss race anif cy. _
n utho Ua ,ro ISSUED BY: �
L
OFFICE COPY