23630 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address:
2 3 6 3 0
L r
.A,.Name: one: p
zss—/$s ,r CITY OF CUPERTINO-BUILDING DIVISION
cam s.Name: Lic:NN.: APPLICATION I PERMIT
GS 'jO�� J' Ui✓ � BUILDING-ELECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL If
RMILINIPM rch., Agineer. LIB No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. PERMETISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ther by affirm Sacti.0000)tlamaboelllicensedhe er Buslrovlaions ofnd Pro Cha
sslorm9(mmmenc APPLIANCES-RESIDENTIAL JOB DEECRB'TION .
Ing wllh5ection7000)ofDivldon3 olthe Budneesand ProfeuloneCode,and m
Iiceneeis In full rce and effect. J!' PAN
I7S r�.�.,a
Data a CI Lie.p .3 "'i `•
Data Contractor
ARCHITECT CLARATION 201.1000 AMPS
rc'LO I understand my plans shall he used u Public records. OVER 1000 AMPS SQ.Fr.FLOOR AREA $/SQ.FT.
0
?i L Licensed Professional SIGNSELECTRECAL g L E p IN
Q�Q
OWNER, UILDER DECLARATION $PECULCU2CUIT/MISC p T E
7F, � Iherebyaflme that l am exempt fromthe Contractors License Law for the
pp following reason.(Section 7LbI.5,Business and Pmtesalone Code:Any city or �a�
O Z r TEMP.METER ORPOLE•INST. ZV
F� cwntywhich requlrcea permltmmns[ruct,alter,lmprove,demolish,orrepair
any.tmocam priori.its ismame,aisorequires theapplicant forsuch permitto POWER DEVICES
O file a signed statement that he is licensed pursuant to the provisions of the
Contractor'.License law(Chapter 9(commencing will,edlon 7000)o(Divl-
L.,��S elon3aftheBustneasandProfewionsCMe)orthatheisexempttherefmmand SWIMMINGPOOL ELECTRIC VALUATION
Sn„ the basis for the alleged exemption. Any violation of Section 70I13 by any // O
<i applicant forapermit subjects the applicant to a civil penalty of not ore than OUTLETSSWITCHESFIA"RlRFS (POD a O
Bvehundred dm
ollzrs($500). NEWRESIDENTIALELECTR
F11,as owner of the property,or my employees with wages as their sole $Q.FT. STORIES TYPE CONSTRUCTION
compensation,will do the work and the swcture is not Intended or offered for
O -1-(Sec.70K Bushtessand Profeaslons Code:The Contractors License Law
j3$ does not apply to an owner of property who builds or Improves t hereon,and OCC.GROUT' RES.UNITS
who does such work himself or through his own employees,provided that such
Improvements are not Intended oroffered forsale.If,however thebullding or TOTAL:
Improvement lasold withmoneyearofcompldlon,the owner-bullderwill have
itrden of proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
61,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
mntradom to consumer the project(Sea 70K Business and Professions Code
The Contractors License Taw does not apply to an owner of property who ALTER-DRAIN k VENT•WATER(EA)
builds or Improve thereon,and who contras for such ppJes with a
C%4-dor(s)Bmrowd pursuant to the Contractors License Law. FEE SUMMARY
^�am exempt under Sec. B A P C for this reawn BACK FLOW PROTECT.DEVICE
OUTSIDE FI
DRAINS-FLOOR RODE,AREA,COND. SANITARY Y_ N
Owner Date RECEIPT M
f WORKMAN COMPENSATION DECLARATION
by affirm that I have•cartift W of consent to self-Erre,or a TURES PER TRAP SCI'IOOLTA% Y N
cenBlcale of WmImm Compensation Insurance ora cenifled ropy thereof(See. RECEIPT M
3800,Lab C.7 . ��72 '�G�Q�,,/� GAS EA.SYSf'EM-1 INCA OUTLETS PARK PEE Y_ N_
iuiI i�Gz' '� GAS EA. RECEIPT#
Co,m n��(M1//$///_rrx� x ( BUILDING DIVISION FEES
Ce IBed mpyis hereby Nmished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHL•CK FEE
crtUed copy is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE $EWER-SANETARY-STORM EA.200F1.. Date Recef [#
(Thls.ection need cad be completed If the permit is(.,..A hundred dollars
($100)or1y thforwhichrmitat WATFRITEATERW/VENT/ELECTR ENERGY FEE Y N
Icl not thatlnthe .sperm performance work.Astobe.thisub)dtotheIssued,
1 shall not employ any person In any manner at as lw become subject to the WATER SYS[EM/TRFATING
Workea'C�mpensation Tawe o(GB(ornh.Date PAID
OZ NOTIan` of NEW RESIDENTIAL PLMB. SQFT. Date Reuel t#
Z O NOIICETO MPLICt to
after rs'Comakinthis sation Certificate of the
Labor
sode,yo a,forthwit the ply with
such
rovisinproWlonermit Labbe TOTAL:
W N
Code, r avast forthwith comply wish such provisloru orchis permit shall be �n
deemed revoked. IN
W
G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there Is a construction lending agency for the perform, ELECTRIC FEE
M Z onceof the wmkfor which this permit is;issued(Sec.3097,Civ.C.) TOTAL:
U O Iender'.Name PLUMBING FEE
LL F Lender'.Addrena QIY. MECHANICAL PERMIT ISE MECHANICAL FEE
O W l mrtifylhat l have read this applicallonand satethattheabovelnformatlon
1 iscorred.Iagree to comply with all city and countyoNlnances and pate laws PERMIT ISSUANCE FEES PAID:
} relating to building construction,and hereby authorize repreentativeeof this
Zcity to enter upon the above-mentioned property for inspection purposes. ALTIRORADDTOMECH.
(WC)agree to save,Indemnify an d keep harMem the City of Cupertino Date Receipt#
V agalnrt llabNilee,jedgmana,massed expeneea which meylnenywayacaue AIR HANDLING UNIT(To 10,000CFM) SUBTOTAL:
ago t said Ci nanquenm of a gr..tieg of this It.
AIR HANDLING UNIT(OVER 10,WOCFM) CONSTRUCTION TAX
Slgnawmol Ap Iica Contra o D EXI LA HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS ATERIALS DIS LOSU0.E
Will theapplicant or future building occupant store or handlL hazardous HEATING UNIT(TO 100,000 BTU) Date Reeei [#
materlal a.defined by the Cupertino Municipal Cade,Chapter 9.12,and the
Health and SafetyCode Section 25532(a)? HEATING UNIT(OVER 100,00)BTU) TOTA
Rill
t �]No
Illthe applimntorraurtamIdingoccupant dby trquhe Bay Area devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which CMI hazardous air mnlaminsnta ae defined by the Bay Area Air pp
Quality Management District? BOILER-COMP(3HPOR 1(10,0(10 BTU) PAID
9
Yon Q No
v h1 -read the hazes sus malerlala requirements un der Chapter 6.95 of BORER-COMP(OVER 100,000 BTU) �p �s
he Callfmnla Health h Safety Cod,Stolons 25505,25533 and 2:534.I - IWAY ss v 19�rS
understand that if the building does not corrently have a tenant,that it 1.my NEWRESIDE-MALMECH. SQ.FT. w 9(
responsibility to nalfy the occvpa of of the requirement.which at be met _ -
pd toisuan of cal tc of c Fancy. _
/f�a�
Owner or aulhorized agent Da -
i. 11 ss
,.. --OFFICE COPY;
.1