23048 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address:
23048
ra am,eN•:Iaroles:
'I ICYy� CITY OF CUPERTINO-BUILDING DIVISION
C. N'"": J i�.Nn: APPLICATION / PERMIT • -
a� BUILDINGELECTRICALMUMBING-MECHAMCAL CATEGORY CONTROL#
Architect/Engiver, Lt.Nin
QTY ELECTRIC PERMIT FEE BUILDING PERMIT'.INFO
Address: BLIJISL
❑ ELI�1:1 ElI'FRhITISSIIANCE
LICENSED CONTRACTOR'S DECLARATION PLUME
I fiereby efflrm thatlam&¢need under provisionso(Cha)aMr9(commrnc APPLIANCESRFSTDENTIAL ]OB DESCRIPTION
Ingwlth Sect) n7000)o(Divldon3 oft eBue son Pro¢eslonaCode,and my PANELS
license /`J LIP
TO2
LlcenseC Lie#
Dale Contractor
ARCHITECTS DECLARATI 201-1000 AMPS
^ZZO Iunderstand my plans,hal be used as public records. OVERI000AMPS _ p//L� SIT
]aGO EA ' 3/SQ Ff.
[acrd �j LicensedPro(eeslovl. 9GN5ELFLTRIFT /„JRL�1 P I UTE R
6 OWNERexNLDERDECLARATION SPECIALCIRCUIT/ E,IR
Zfp, a owing .an.(thatlam31.5,Bxempt(romthe ContractorbaCadee Law forth¢
O q
following reason.(Se tion 7Qi1.5,Buslnew and Pm(esalone Code:My sty or
rZf'sy =ntywhichrequimsaperm(ttommtmd,alter,Impmve,dem lWh,orrepalr TFMP.METER LE INSC.
X37 anyatmu mpriortoltahwane,alsomquirestheapplimntfarauchpisotto
file a signed statement that M ro
Is licensed'pursuant to the pvisions of the ]OWER D CFS aear��
Contractor',License Law(Chapter9(mmmeneingwith 5etion70W)o(Divl-
'; don3ofthe Budnessand ProfsmiomCode)orthat hetsexempttherefromand SWAT GIOOL ELECTRIC VALUATION
the basis for the alleged exemption. Any violation of Section 71111S by any I
.yam applant fora permit subjects the applicant to a civil penalty of not more than O ETSSWITCHESFIXTURES
cR five 1,--- .1ofdeltathe
NEW RESIDENTIAL ELECIR SQ.FT. STORIES TYPE CONSTRUCTION
j.. ❑I,as owner of the property,or he employees with wages r their dole
compensation,wasdoth¢work,andthes Code: is final Intendedo License
Law
O
sale(Sec.ppy to simssand f property who
Contractors License law
$ does not apply to an owner a property his o builds or Improve thereon,and OCC.GROUP RES.UNITS
EE whnovesa.chents amrkMmeendedorough Naown e.If,ho evert ded that ebuildIsuch
Improvementsarena Intended earofredforeio ILh er-g deer buildIngTOTAL:
Improvement beold wrthinoneyearofctnplalorytheowner-builderwllhave
tfpjJurden of proving that he did not build or Improve for purpose ofukJ. Ory. PLUMBING PERMIT FEE FLOOD TONE APN
Lf L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to consec construct the project(S 7094 Business and Professions Code:
The Contractor's License Law does not apply to an owner a property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon,and who contracts for such pikojet -
a with a FEE SUMMARY
�gRt��ctor(d)licensed pursuant to the Contractor's License Law, BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B&P C for this reason
DRAINS F1,00 ROOF, SANITARY Y NOUTSID_
. ES
as'ner Date R AREA,��' RECEIPT#
WORRMAN COMPENSATION DECLARATION F.IX.IVRES PER TRAP SCHOOL TAX Y_ N_
I hereby affirm that I have a trtlBcate of consent to self-insure,ora - RECEIPTN#
c late ofW-gdseis'C matlonll uragce oracertlfled mpythemot(Sec. GAS EA.SYSTIM-1 INCA OUTLETS PARKFEE Y N
3800,lab CJ lla�y[t,a-� —Lal/LL_JL
Paltry p 'r 1 RECEIPT If
Com any_'33 GAS EA.SYSITM.OVER d(EA) BUILDING DIVISION FEES
[PCegmed ropy lrelay rthe city GREASE/INDUSTRL WASTE I EPTOR PLANCHECK FEE
�ertlied copy b fled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWERSANITARyS RM EA.200FT. Date Recei tIY
(Thiaeetlon need nt firs complied lithe permit la(orov hundred dollars
($100)orfess.) WATER HEA /vENT/ELECTR ENERGY FEE Y N
Icertifythat lathe performancea(the work forwMch this permit I.Issued,
r 'I shall not employ any person In any manner sou to become subject to the WATER SY /TREATING
Worken'Compenvtion Iowa of Calllornla.Data PAID
O Z Applicant Date Recei HI
Z (] NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW DENTAL PLMB. SQFI.
should become subject to the Workers'Compemation provisions of the Labor TOTAL:
O) Code,you=at forthwith comply with such provisions or this permit shall be
� > deemed revoked.
BUILDING W E3 CONSTRUCTION LENDING AGENCY SEISMIC FEE
a G Ihereby afftrmthat there is a construction lending agency forthe perform- ELECTRIC FEE
O ante ofthe work for whieh this permit la Issued(Sec.3097,Civ.C.) TOTAL:
i.V lenders Name PLUMBING FEE
LL I— Lendees Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I mitifythatl have ad this liatfonandstatethattheabove lnformaiton
G is corned.I agree to o plywith all cttyand countyordlnance,and state lawsPERMIT ISSUANCE FEE PPAID-
} N relating to buildin co traction,and hereby authorize rcpresentat lvea this -
F Z city to enter upo he mentioned property for Wpection purpose. ALTERORADDTOMECH. Dale - ROCeiFa[Il
V — (We)agree t ave, de ify and keep harmlss ethe City of Cupertino
agalmtlibilid ,judg n costeandexpenssswhich mayinanyw cenu R HANDLING UNIT ITO to,"CFM) SUBTOTAL:
againstsald Ci in. it tin t apermit.
S AIR HANDLING UNIT(OVER la"CFM) CONSTRUCTION TAX
Signatureo(A Ilan Contractor -
Data EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
RDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei IN
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
Health and Safety Code Section 25532(x)) HEATING UNIT(OVER 100,000 BTU) - TOTAL•
r-1Ys' r]No
Will thedppliant or future building..part use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants a,defined by the Bay Area Ale
Quality Management District? BOILER-COMP OHP OR 100,000 BTU)
PYas II��No
havereait the hazaaouamatedalsrequirements under Chapter 6.95of MOILER-COMP(OVER 100,0M BTU)
the Califomla Health&Safety Code,Sections 25505,25533 and 25539.1
respontandthat lithe the
ing occupant nor a rrently equire ave encs which must
that b met NEW RESIDENTIAL MEIN. SQFT.
undeni imllt to li the the occupant ofthe requirements whichmuat It met
prior to Laniance of a Certificate ofOtupancy.
Owneroraulhom,c agent Date ISSUEDBY:
TOTAL
OFFICE COPY