23637 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERWTNO.
Building Address: 1� RD 23637
ners one: A A
.me. CITY OF CUPERTINO-BUILDING DIVISION �� 2
��^ ' ^p ue.N APPLICATION / PERMIT
r N BUITDINGELECTRICAL-PLUMBINGM EIAMCAL CATEGORY C
Architect/Engleae Lk.No:
)37
Q' ELECTRIC PE T FEE BUILDING PERMIT INFO
`JS/� 9i
Address: lyr(ypr f4a&. Tja 4,1A 0,A PERhITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
hereby affirm that l am licensed under provisions ofChapter 9(rommenc AP NCESRESI E L JCU DFSC N
ingwith Suction 7W0)of Mvlsion3ofthe Businessand PmfevlonsCode,and my
license is in(uO fo and affect. ..{..�_
LiE'I'' 6 Llc N a/l r/0/ 0 1
Date_(A Contraam .L3
_b ARCHITECTS DECLARATION V � SQ.FI'.FLUOR AREA S/SQ.FT.
p'/, Iundersta�NatNB Ee sed as public records.
60 O `_ 1.24
Licensed PmfevWnal CANS ELEC A I61 m
�a OWNER-BUILDER DECLARATION SPECIALCIRC LSC N
E, Iherebyaffirmthatlam exempt lromtbe Cont rectors License Law for the
7.O following reason.(Section 7(01.5,Business and Professions Code:Any city or
C Z TEMP.METER POLE 14T.
coantywhkh rcqulresapermitroconstnct,alter,bnprove,derrollsh,orrepalr
�e anystructure pdortoitslvuame,alsomquimstheappllant for such permit to POWER DEVICES
5
I. file a signed statement that he b licensed pursuant to the provisions of the
3 t:� Contrachu'sLicense law(Chapter9(comnnndngwith Section 7000)of Divi- SWIMMING POOL ELECTRIC Ile I 171
TION
cion 3 ofthe Business and Professions Code)or that he b exempt therefromand
G5p7 yl the baele for the alleged exemption. Any violation of Section 7031.5 by any (1n,E.CSSN7TCI7GSpIXT.UREq L
applicant fora permit subjectsthe applicant to a civil penalty of not more than - 1
c five hundred dollars($500). NEW RESIDENTIAL ELECTR� SQFT.7 6
F1 1,as owner of the property,or my employees with wages as their sole STORIES TYPE CONSTRUCTION
compensation, bot will do the work and the structure nIntended or offend for
9 O vie(Sec.7014,Business and Professions Code:The Contractors License Taw
$ does not apply to an owner of property who builds or improves thereon,and
mss^ whodoeasuchworkbimselforthroughhisownemployee,,providedthatmch OCC.CROUP RFS.UNITS
improvements are not intended oroffered forsale.If,however,thebullding or
improvement bsold Mthinoneyearofcompleliogtheowner-buBderwill have
theq*rden of proving that he did not build or Improve for purpou ofsale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
u L as owner of the property,am exclusively contracting with licensedI PERMIT ISSUANCE
contractors to construct the project(Sec.7074,Business and Professions Code:
The ContraRors License Law does not apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
Wilda or improves thereon,and who contracts for such projects with a FEE SUMMARY
rt.[aew(s)Rrenud pursuant folie Contractors License Law.
LJ 1 am exempt under Sec. B A P C for this mason BACK FLOW PROTECT.DEVICEOUTSIDE FEES
DRAINS-FLOOR, A,ROOF,ARECOND. SANITARY Y_ N_
• Owner Data RECEIT N
WffiORK MAN COMPENSATION DECLARATION FEKTURES PER TRAP �� SCIiOOLTA% Y N_
F-11 hereby arm that I have a certificate of consent to self-insure,ora RECEIVE M
certificate of Workers Compensation Insurance or a certified copythereof(See. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEF. Y N
3800,lab C3 RECEIPT N
Pull,N T.1932GAS E.A.SYSTEM-OVER 4 MAI BUILDINCDI :ES
ny CTYr e✓ ♦—t1 Jp
rtlfled copy b hercbyfumished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHE - E
Certified copy b filed with the city inspection division. 3 Qti7a1
CERTIFICATE OF DEM PTION FROM WOR K ERS' GREASE TRAP A
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.2ooFr. a ReceI
(This senio^read act he completed if the permit b torose hundred dollars
($100)or rev.) WATER HEATER W/VEM/FlECTR YF Y
Ice notAifthatin oy an person in
he meaner
so as tobeco become is subject
' /-
1 shall not employ any person In any manner ao as to become subject to the WATTR SYSTEMMrATING L_•�`7a
Worker Compenvtlon Laws of Califomh. Date PAID L
Z Z Applicant NEW RESIDENTIAL PLMB. SQFr. Date eCel t#
Z
O NOTICE TO APPLICANT.ILafter making this Certificate of Exemption,you
Fshould become subject to the Workers Compensation provisions ofthe Labor TOTA
N Cade,you must forthwith comply with such provisions orthb permit shall be BUILDING FEE
W7 deemed revoked.CONSTRUCTION LENDING AGENCY SEISMIC FEE _
CL Ihereby affirm that there b construction coction lending agency for the perform- T ELECTRIC FEE
7 Z arta nnne work Wrwhkbmb permit's Wuad(see.3D97,cw.c.> PLUMBING FEEU O Larder:Name
LL I— Lredar,Addres, QTY. MECHANICAL PERMIT FEE MECHAMCALFEB r—
V Icertifythat l have read this application and state thattheabove information
O W is correct.I agree to comply with all city and county ordinances and state laws PERMITISSUANCE FEES PAID:
>. a relating to building construction,and hereby authomen mpreuntaives ofthb 1
H Z city to enter upon the abova,mentioned property for Inspection purposes.' ` ALTIXORADDTOMEOH.
Me)agree to save,indemNfy an d keep harmless the City of Cu NAW, Date Receipt#
V against
t liabilities,Judgments,costs and expenses which may in any way accrue AIR HANDLING UNIT(TO 10,ODO CFM) SUBTOTAL:
against said City in consequence of the granting of this permit. AICONSTRUCTION TAX
R HANDLING UNIT(OVER 10,000 CFM)
5 wturc o(AppBant/ actor Da H IXHAl15THOOD(W/(W/DUCT)) CONSTRUCTION TAX PAID:
HAZA DES MATERIALS DISCLOSURE
Will theapplicard orfuture building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCC f#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
Y-10110—
licalth and Safety Cod ion 25532(a)i HPATING UNTT(OVER 100,000 BTU) TOT L.
[3 yes
Will theappliant or tvre No Wilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which cent hv
ardous air contaminants as defined A.by the Bay AAir -` • t.i
Quality Management Dstrid? BOILER-COMP OFI'OR 100,000 BTU) �x 1
4 Yea No AUG 1 v 1
have read the h smateriab rcquircmenb under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) 992
the Callfcmia Health k Safety Code,Sections 255GS,25533 and 25534. I Oy
understand that ifthe building does not currently have a tenanL that It b my NT:W RESIDENTIAL MECJL SQ.FT. Qresponsibility to notify the occupart ofthe requirementswhich must W mat 7��VVr6I71 jFf
Inform issuance of a Certificate of Occupancy.
Owner or authorized agent Date T ISSUED6
OFFICE COPY