23501 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
tluildln Pm'ed lJentlflotlon /111�a� u\ r /O�'1� Q PERMIT NO.
iluilding Addmss: ` l� 1, LL-v 23501
CD SLi%o h a ✓/� IJ PF'�'/�ot
ere
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CITY
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4iP I O CITY OF CUPERTINO-BUILDING DIVISION
cotta •.N Lie.No:(� APPLICATION /PERMIT
'S
`��l� BUILDINGS.BCTMCALPLUMBINGMEGHAMCM, CATEGORY L
• ArcMlea/ gimes'. L e No:
ELECTRIC PERMIT FEE BUILDING PERMIT INFO
QrY
Address: PERMITISSUANCE �� Na ❑
LICENSED CONTRACTOR'S DECLARATION
IMreby ectionrm0)o(Di that I sion3 ftheunder Bumessaons.f Chapter9(conunmc APPLIANCESRESDEI4IIAL JOB DESC ON
If...hSection7 res,anDlWect. (the BuslneasandlarcfeasionsCode,and my
license la in fuB rce and affect. /J./� PANELS
LlcenseC LRCM 77 J1 T
Dat _ ConeraC��G
ARCHITECTS DECLARATION 201-IODOAMPSOVERIOWAMPS SQ.FT.FLOOR AREA 5/�.ET.
a 7 I understand my plans shag be used as public records.
06
Licensed Pmfessionsl SIGNSELECTRICAL
OWNER-BUILDER DECLARATION
Yrs Fn SPECIAL CEtCNT/M75C
CC Ihercby afllrm that]ani exempt fromthe Contractor's License law for the
Ot-� following reason.(Section
'EB 1.5,Business and Professions Code:Any city or TEMP METER OR POLE INST.
�p countywhich rcquimsa permit tocommua,alter,improve,demolish,or repair
q � anysmuaure priorto its Issuance,also requiresthe applicant forsuch permit to POWER DEVICES �Q
15 file a signed statement that he is licensed pursuant to the peovislom of the `�
.03 a
Contractor's License law(Chapter 9(commencing with Seaton 7000)of Divi- SWIMMING IDOL ELECTRIC ^�V LUATION
O the basis
fa the alleged exemption. Any)viothat lation I exem therefrom and a�
Q the bash for the alleged exemption. Any ttolatlon.f Beetles na UTLEISSWITCIMFSHXTIIRES
by any I 1
666 app0mnt fare permit wbjrclsthe appllcam tett avil pemltynfnamore than
five hundred dollars(W. SQ FT �
< n I,as owner of the property,or my employees with wages as their sole NEW RESIDENTIAL ELECTR C Ty'[KQJ CTION
compensation,will do the work.and the smumm is nm intended ar offered for WAIL C I 'V
5 r3, ❑ sale(5m 70M Business and Professions Code:The Committees Liceme Law
$ doesnot apply toan owner of property who Wilds or Improves the.,and 5
who doessuchw.rkhim.elfmiluough Ms..employees,provided thatsuch
improvements are not Intended oroffere l foraale.If,hcwevep the W ilding or T
bnprovement hwld within one)earof complellom theowner-W Iderwill have
t rdemot paving that he dktnot Wilder improve for pueposeofsale.). QTY. PLUMBING PERMIT I FEED
1_J L as owner of the property,am exclusively contracting with licensed PERMITISSUANCE
contractors to comtmd the project(Sce.7044,Business;and Professions Code:
TM Contractor's License law does mat apply to an owner a property who
Wilds or Improves thereon,and who contracts for such Injects with a ALTER-DRAIN&VENT-WATER(EA)
c9lill+ttn
or(s)licensed pursuant to the Contractor's License Law. BACK FLOWPROTELT.DEVICE FEE SUMMARY
IJ I am exempt under Sec B a P C far this m.aOUTS I DE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEDT R
WORKMAN COMPENSATION DECLARATION FIXTURES-PER TRAP SCHOOL TAX Y N
�1 hereby affirm that I have a certl0rate of consent to set(-Insure,or a RECEIPT M
certificate of Workers'Compe/matlon Insurance ora certified mpythereof(Sm. GAS EA.SYSTEM-I INCAOUILEIS PARK FEF. Y N_
F.11Lab Cd 3L.,'7/
Policy a /-DD_/ GAS EA.SYSTEM-OVER 4(EA) RECEIPT M
�7% - FV BUILDING DIVISION 4'EIiS
'FaErerllfled copy W hereby furnished. PLANCHECK FEE
Lf Certlfied copy ht filed with the city irupettlon division. CREASC/INDUSIRL WASTE INTERCEPTOR
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCEgE(yEµ.SpN(TpRY.S'[012M EA.XIOFT. Date RcCCi t#
(This section need not be completed If the permit is forom hundred dollars
WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
I certify that in the ped.rmance of the work forwNch this permit b iswed,
I shall not employ any person In any manner w as to become subject to the WATER SYSTEM/TREATING
Worken'Compensatlon laws o(Callfomla.DPAID
Date
-
0 Z Applicant NEW RESIDENTIAL PLMB. SQFI. Date Recei t#
Z O NOTICE TO APPLICANT:IIf,after making l his Certificate of Exemption,you
P should become subj ce to the Wormrs m
e 'Copns
eation provisions ofthe Labor TOTAL:CC _
n Code,you mu at forthwith comply with such provisions or this permit shall be BUILDING �a
deemed revoked.
UI — CONSTRUCFION LENDING AGENCY SEISMIC FEEa C 1herebyafRrmthathem isaconstruction lendmgagencyfortheperform, ELECTRIC FEE
M 2 ince ofthe work forwhichthLs permit is issued(Sec.3097,CIv.C.) / PLUMBING FEE
() O I<Mer's N.
LL F Lenders Add rem - QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I ramtythat l have read this application and statethatthe above information
isrorc
IL rd.l agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
r relating to building construction,and hereby authorim representatives ofthb
I" V) sty to enterupon the abov�menti.red property for Inspection purposes. ALTERORADDTOMECH. Date Rceeipt#
_ (We)agree to save,Indemnify an d keep hatred.the City of Cupertino AIR HANDLING I1N7f(f010,000 CFM)
againsth.bilitis.,judgments,costs andexpenxa Ichm.yinanywayacaue SUBTOTAL:
agaimtsai uy In mnxquen sof gra i of this permit CONSTRUCTION TAX
d AIR HANDLING?MIT(OVER IO,000CFM)
. gmu of'fAAq —111
A c t/C 'actor Date E%HAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
ALkRDOUS MATERIALS DISCLOSURE
Will the app cant or future building occupant store or handle ha,erdous HEATING UNIT(TO 101000 BTU) Date Recei t#
nuterial as defined by the Cupertino Municipal Code,Chapter 9.17,and the
I lcalth a ad Safety Cud'�aSne}�°"2553](.)? HEATING UNIT(OVER IWOW BTU) TOTAL:
E]Yes I9 1°
Will the applies at or future bu ilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazard....+,cont. mats.,defined by the Bay Area Air
Quality Mawgement Distrl o BOILER-COMP OHP OR100,000BTU)
4Yes
have read the haza ous materials requirements under Chapter G95 of BOILER-COMP(OVERI00,000BN) B
the GlifornU I le.lth A Safety Code,Stolons 75505,25533 and 25534. I
understand thatlfthebullciing does not currently have a tenant,that it is my NEWRESIDENTIALMECH. SQtT
resp.mibllit toraify theoccupantoftherequi ntswhichm atWmM pit tr� vF� �TL It
prior to ncc ofa Certifica of Fnapan
MAY a ;ate
neror authorlrad nt DateC ISSUEDBYos? f. :Y(IIIVIJ
TOTAL:
OFFICE COPY