23437 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
tluiidin Yra'et Identification O 1 ' i11 w— a I'tJiMIT NO.
Building �vVI OI-1 PX 23437
Owmrll are: I - one: APPLICA it 5RTU99T7TA_UI3=A
2 SS lLVl +1 .1,215 5 2_1 CITY OF CUPERTINO-BUILDING DIVISION -2—r—Z'2—�1
Ga c(rp/sa Lic* APPLICATION / PERMIT (�
1_' BUILDINGELFCTRICA mP BINGmrCHANICAL CATEGORY C
Architect/Enginee'. a Lic.No:
QTr ELECTRICPERMIT FEE BUILDING PERMIT INFO
Iof�ol S uEM+ IJ. it
Address: PERMITISSUANCE
LIC.NSEDCONTRAR R'SDECLARATION
I hereby afirmthat l am licensed under pr.vislonaof Chapter9(com renc APPLIANCESRESIDENIIAL ]OB DESCRIPTION
ingwith Section7000).1DMslon3ofthe Budnemand ProfessionsCode,and m TIT I
license is In full force and effect. PANELS
License Clea Lle.X
Date Comrator
ARCHITECPSDECLARATION 201-1000 AMPS
�2 I understand my plane shall be used ss public recorda. OVER 1000 AMPS SQ.FT.FLOOR AREA E/SQ.FT.
Z° ►
Licensed Professional SIGNS ELECTRICAL y
�p<$ OWNER-BUILDER DECLARATION SPDCIALCRCUIT/MISC "\
IhercbyafRrm that l am exempt from the Contractor's License Law for the
Q followingresson.(Se«lon7M15,Bualnmand Pmf.I.raCode:Aoyctyor TEMP.METER OR POLE INST.
rill caantywhich requiresa permittoconstmt,alter,improve,demolish,ormpair
any Stmcturepriortolta Lsaaancgal mqulreatheappUmntforsuchpem tto POWER DEVICES
file a signed statement that heIs licensed pursuant the proof the
Contractors License l
onase(Chapter 9(commenciwith Sectionof Divi.
SyAhNGPOOL PIECTRC
alon3ofthe Bussesa and ProfessionsCade)orlhatheisexeptiherefromand �VAL�U ONX
G S the basis for the alleged exemption. Any violation of Section 7MI.5 by any OUTLETS-SWITCHESFIXTRRESL
appBcant fora permit subjects the applicant to a civil penalty of not more than
c, O five hundred dollars(&50(f). NEW RESIDENTIAL ELECTR .FT.
$^�, M I,as owner of the property,or my employees with wages as their sole STORIES TYPFvCONSIRL'CTION
compensation,will do the work and the structure Is ran Intended or offered for
X.... D '
5 p sale&c.7044,B.alness and Professions Code:The Contractors License Law
E...
Q' $ docs not apply to an owner of property who Wilds or lmprnms thereon,and .G RFS.AMTS
a who does such work himself orthrough his own employees,provided that such
improvements are not Intended oroffered for sale.If,however thebullding or Tdw SIG
improv nt'scoldwithinoneyear.fcompletioNtheowner-budderwillhave
t"mien of proving that he did not Wild orlmprove forpurposeofsaled. QTY. PLUMBING PERMIT DAM
I_I L as awner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the pe,je t(Sec.70K Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who
Wilds or improves thereon, and who contracts for Such ptojets with a ALTER-DRAIN&VENT.WATER(EA)
a tt(aetor(a)Ikensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
IJ I am exempt under Sec. B&P C for this reason
Owner Date
DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y_ N_
RFLE
• N
WORKMAN COMPENSATION DECLARATION Fp(TI]RFg TRAPPER TRSCHOOLTAX Y_ N_
1 hereby affirm that I have a certifcate of consent to Self-Insure,ora ftECEB'f N
irate of Workers Compensation Insurance or a certified copy thereof(Sea GAS EA.SYSTEM-11NC.40L)TLh-IS �► PARK FEE Y N
W,Lab C.) RECEIPT X
Policy X GAS EA.SYS`EM.OVER 4(EA)
Cam any BUILDING D 1510N FEES
�CertBied ropy b hereby furnished. GREASE/NDUSIRL WASTE INTERCEPTOR PLANCHECKFEE ^ 11
Certified copy is filed with the city inspection division. - `2
CERTIFICATE OF UEM PFION FROM WOR K ERS' GRE-ASE TRAP PAID _
mCOMPENSATION INSURANCE SEW FR SANITARY STORM EA 200FL Reccj
(Fhisslon need not be completed lithe permit Isforono hundred dollars
(SLorless3 6t
WATER
I E Y #_171
L�certify that th the performance of the work(orwhl<h this permit is issued, L7
I shall not employ any person in any manner w as to become subject to the WATER SYSTEM/TREATING
Workers Compensation laws I California.Date ID
O Z Applicant NEW RESIDENTIAL PLMB. SQFr. Da1CNpipol
Z 0 NDUCETO APPLICANT-.If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions ofthe Labor TOTAL:
� f/1 Code,you must forthwith comply with such proWlans orthis permit shall be BUILDING FEE
deemed revoked. SEISMIC FEE _
III IFONSTRUCFION LENDING AGENCY
CL Ihembyafftrm that there be construction lendingagency for the perform- T ELECTRICFEE
M Z ante of the workfom which this permit V Issued(Sec.3097,Cte.C.)
02 UndersN. PLUMBING FEE
LL r Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U Icertifythzt l have read this application and statethatthe above information FEE$PAID
O W is condin
ed.I agree to comply with all city and county ordinances and state laws PFRMRISSUANCE
} a relating to building construction,and hereby authorize representatives of this
I.- Z city to enter upon the above-mentioned property for inspection purpows. ALTFRORADDTOMECH. Date ReCeiptN
(We)agree to save,indemnify an d keep harmiess the City of Cu proton
V against liabilities,Ndgments,mets and expenses which may in any way accrue AIR HANDLING(INR CFO 10,=CFM) SUBTOTAL:
againstsald Cityln naequ nceofthe gramingofthls it. CONSTRUCTION TAX
Al AIR HANDLING UNIT(OVER 10,000CFM)
SI re of Applicant/Contra Data EXHAUST HOOD(w/DUCD CONSTRUCTION TAX PAID:
HAZARDOUSMATERIALSDISC SURE
Willtheapplicant orfuture building occupant store or handle hazardous HEATINGUMT(TO100,WOBTU) Date Re i
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Ilealthand Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BM T L•
❑Yes In No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESIO) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
QuA ty Management Distriet7 BOILER-COMP DIiIPOR 100,000 BM
4 Yes No
have read the hazy ous matedab requirements under Chapter 6.95 of BOILE2COMP(OV[R 100,000 BTU)
the California Health&Bafety Code,Setiore25505,5533and2SS34. I P A I D
understand that lithe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT
responsibility to nt BI"he occupant of the requirements which most W met
prior to Lasuanee of a Cenificate of 0<apancy.
Ownerorauthorludagent Date ,roT ISSUGD BY: BVI 1 t'lDs7
OFFICE COPY