23457 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — US513ALL POINT PEN ONLY
Building Prom Identification If\'f� PERMIT NO.
U �Vhl I ' � 23457
t s me: one: A
C �V\dy CITY OF CUPERTINO-BUILDING DIVISION — L 2—
SwIle.a.r•.Name: Lie.N. APPLICATION I PERMIT N
BUILDING-ELECTRICALPLUMBING-MECFIANICAL CATEGORY CONTROL N
rchitcct/EngiMer. Lie.No:
p QTY ELECTRICPERMIT FEE BUILDING PERMITINFO
Address: ` ` PERNUTISSUANCE S O El ElLICF.NSEDCONTRA OR'S DEC"I ATION
!hereby ail that l am licensed under provbions o(Chapter 9(commene- APPLIANCES—RESIDE J BDES(ZERMON
IngwithS ion7000)o(DiWsim3ofthe Businessand Pref lonaC-ode,andmy
license 191n fol feel. P
Licen lam Lk.
Date Contractor �•�/ L AM
HITECPS sAxZ
DEC RATION VER1000 A. SQ.FT.FLOOR AREA S/SQ.FT.
7O I understand my platy shall be used as public records.
Z�j Licensed Professional SIGNSELEC AL _OO C
6 OWNER-BUILDER DECLARATION SPECIAL CIR T/MLSC L E D IN
L., I hsmbyaffirm that Iant exempt fromthe Coneradm'a Limnse lawforms
following mason.(Seelon 7031.5,Business and Profusions Code:Any city or TEMP.METERORPOLEINST. =op� T Ecounty which requlresa permit to construct,alter,improve,demolish,or repair
aoystrocture prior to its Lssuance,aLso requiresthe applicant for such permit to POWER DEVICESryfile a signed statement that he Is licensed pursuant to the provisions of the y G-
09� ContnRor'sLicenselaw(Chapter9(commencingwithSection7000)ofDiel- SWLMNBNGPOOLELECTRIC DATON
O sion3ofthe Business and ProfessionsCode)orthat he is emmptthemfromand _ /-�
Q the basis for the alleged exemption. Any violation of Section 70315 by any OUiLE.ISSWI.ICI IESpIXNRpS'ITI /1 D • O !/
applicant for a permit subjects the applicant to a civil penalty of not room than l V
five hundred dollars 0500). NEWRESIDENALELECTR SQFT. RIES TiTE CONSTRUCTION
1,as owner of the property,or my employees with wages a their sole
%¢ compensation,wllldothework.and thestructure is not Intended or offered for
p sale(Sec. pply to ainowand Improves
mprovLIcenselaw
g docs not apply to an owner of property who Wilds orimprovesthereon,and OCC.CROUP RFS.UNITS
who does such work himself or through hbawn employee,provided that such
Improvements are not intended or offered for sale.If,however,the building or TOTAL:W-Q
improvement is sold within oneyearofcomplellon, he owner-bu 0derwlll have
tIS. el en of proving that he did not boils or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
I_f L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7014,Business and Profeebm Code:
The Contractor's License Law does rad apply to an owner of property who ALTE[t-DRAIN&VENT-WATER(EA)
Wilds or improves thereon,and who contract, for socL ptojeab with a FEE SUMMARY
,,nfdt(ractor(.)licensed pursuant to the Contractor's License Law. BAIX FLOW PROTECT.DEVICE
LII am exempt under Sen B&P C for this mason
OUTSIDE FELS
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
Owner Date RECEIPT N
WORKMAN I have
DECLARATION FI%TURF_S PER TRAP SCHOOLTAX Y N
❑f hereby affirm that I have a certlBnte of consent to self-Inwre,ora RECEIPT N
certificate of Workers Compereation durance ora certified copy themed(See. GAS EA.SYSTEM-1 INCAOUTLE7S PARK FEE Y N
380.1,Lab CI REGEIIrI'N
Policy N
Com GAEA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
an
S
�Cenu(led copy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
.F,2(2ertUied copy b filed with the city Inspection division.
T� CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200Fr Date Recef t#
(Phis action need not he completed If the permit b for one hundred dollars
(SI00)or less.) - WATER HEATER W/VFNI'/d[CTR ENERGY FEE Y_ N_
I certifythat in the performance of the work forwhich this permit Is issued,
I shag not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workers Compensation Laws of California.Date PAID
—
0 Z Applicant NEW RESIDENT[ALPLMB. SQ.FT. Date Recei t#
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should become subject to the WorkerCompensation provisions of the Labor TOTAL:
1' 0 Code,you must forthwith comply with such provisions or this permit shall be BUILDING FEE • 9 D
2 j_ deemed reme,ked. SEISMIC FEE
W CONSTRUCTION LENDING AGENCY
a Ihercbyaffirmthatthem baconrtructionkndingagencyfortheperform, TOTAL: ELECTRIC FEE 3Q 00
D Z ancoofthe work for whichthb permit is Issued(See.3097,CIv.C.) PLUMBING FEE
02 Icnder'.Name
LL I– Lender',Addres. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
W I metifythzt I haveread this applicauonand stawthattheawve infmorginn FEES PAID:
Is correct.I agree to comply with all city and county ordinanms and state laws PERMIT ISSUANCE
O
} L relating tobullding construction,and hembyauthorim repre.m.threaofthis
Z city to enter upon the awo-
vmentioned property for impemon purposes. ALTFIRORADDTOMECH.
(We)agree to some,indemnify an d keep harmless the City of Cupertino Date RcCeiPt#
V
against liabilities,judgments,cost9and e.pc..whkh may In anywayaomme AIR HANDLING UNIT 17010,000 CFM) SUBTOTAL:
a ai .ascii in con.equen fthe granum dthls permit CONSTRUCTION TAX
AIR HA NDLING UNIT(OVER 10,000 CFM)
Sigwtureo(Applican ntractor thate N/ E(IIAUST HOOD(WI DUCT) CONSTRUCTION TAX PAID:
HAIAIR DOUS MATERIALS DI SCLOSURE
Will the applies rat or future building occupant store or hand Is hazardous IR'ATING UNIT(TO 100,000 BTU) Date ReCel t#
material as deft ned by the Cupertino Municipal Code,Chapter 9.1 7,and the - ----//))
I lnalth and Safety Code Section 25 532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
F-1Yes
Will the applicant or(antro building occupant use equl nt or device, VENT!LATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haaardous air contaminants as defined by the�y Area Alr
Quality Management District? BOILER-COMP(3IIPOR 100,000 BTU) p
Yes No r p�S pe, 1 D 41❑I hame read the hazardous materials requircmcnts under Chapter 6.95 of BORER.COMP(OVER 100,000 BN)
the California health&Safety Code,Scutum,75505,MS33 and 25534.I
understand that if the building don not currently have a tenant,that it is my NEW RESIDENTIAL MECH. '.Q.FT MAR 26 1992
responsibility to notify the occupant of the mquiernents which most be met
prior to issuance of a Certificate of Occ npancy.
CIIYU' IUF n1
`B1VU
Owner or authorized agent Date TOTAL: ISSUED BY-.
OFFICE COPY