23107 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildln Prat ed Identification PERMIT NO.
Building Address: . . 23107
5
,�`�ro ams''`` ''LL,�� � .
Cd YQ A- 5 - W 6 CITY OF CUPERTINO-BUILDING DIVISION
cono-aet Name: : APPLICATION / PERMIT '
VY aN _ UDING-ELDCTRICALPLMBING-MECHAMCAL
CATEGORY CONTROL M
Architect/Engineer. -- LM.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:
PERMITISSUANCE ❑ ❑ , ❑
LICENSED CONTRACTOR'S DECLARATION
]hereby affbrn that l am licensed under provision.of Chapter 9(commena APPLIANCES-RESIDENTIAL - JOB DESCRE'TION
Ing with Section 9000).1 Division 3.fthe Business sitdProfeaslonsCode,and my
L=
is in to impend effect. PANELS
License Cla in 0"
Dale onhact. (�-�[�
ARCHITECTS DECLARATION 2(11-1000 AMPS
q�+aO Z0 I undeist.ml my play.h.H be used as public rerords. OVER 1000 AMPS SQ.Fr.FLOOR AREA S/SQ.Fr.
W (0 Licensed Pmfemlorul SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION
z "a Iherebyafflrmthat l am exempt fromthe Contractor's License Law for the SPECLILCB2CDIT/MLSC
O ZZZZfollowing recon.(Section 7011.5,Business and Professions Code:Any city or �p MEppg ORPOLE INSC.
P4 countywhichrequiresapermlttomrutruRalter,Improve,demoWh,orrepair
a anystmciurepri.rtoltsbmance,abonquimstheappllcentforsuchpeimitto POWER DEVICES,
NK U file a signed statement that he is ticensed pursuant to the provbios of the
3 w0 f� ContraRor.License Law(Chapter 9(commencing with Section 7000)of Divi. SWIMMING POOL ELECTRIC
.17 slon 3 of the Business and ProfngkrgCods)or that he b exemptthere(rom and VALUATION
See the basis for the alleged exemption. Any violation of Section 70315 by any
G OUTLETS-SWITCHES-FIXTURES
applicantpermit subjects the applicant to a civil penalty ofnat ore than
m
five hundred dollars%M. z
NEW RESIDENTIAL ELECTR .Fr.
�n ❑I,asowner of the property,orhestructure
employees with ween atheir sole SQ STORIES TYPECONSTRUCTION
rom(So:.7 0AwRldothe wok,and kog m h,:The
not Intended or offered for
O sale(Sec. pply Boo,hto an owner
property
Cade:The or improves
License Law
3 don nor applytork ownerofpropertywhobuilds orimprovesthereoryand OCC.GROUP RES.UNITS
whoovementswork MmseBedoroughedownemployees,p ovided,theb ihats.or
improvement wldwim not nlendneyear fcompr to.th h.wevep deer ill have TOTAL:
Improvementtsoldwithlnoneyearo(complstiorylhe mvner-bullderwillhave '
t11L,Ttrden of pmrove
vingthat he did nor build or lmp (or purpose ofsale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN "
u I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE F'
contractors to construct the pm*d(Sec.7044,Business and Professions Code-
The
The Contractors erty
License Law does not apply to an owner of prop -who ALTFRDRAIN&VENT-WATER(EA)
builds or improves therein, and who contracts for suck pt. b jecwith. -
nactor(s)licensed pursuant to the Contractors License Law. FEE SUMMARY
I am exempt under Sen B k P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,CONED. SANITARY Y N
Owner Date RECEIPT#
I. WORKMAN COMPENSATION DECLARATION 7•TXMtES PER TRAIT - SCHOOL TAX Y N
I hereby affirm that I have a adif este of consent to selNnsure,ora RFfEBrI'p
cehifi ateofWorkers'Compematlonlruuranceo.ndified ropythemof(Sec. GAS EA.SYSITM-1 INCA OUTLETS PARK FEE - Y. N
3800,Lab C.),t,.n
Polli,y# 0111"700 Lir—� RECEIPT 0 .
Com anv] GAS EA.SYSTEM-OVER4(EM BUILDING DIVISION FEES
[ferruled copy is berebyth the cid. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
' �2F�ed copy b filed with the city Inspection division. '
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP
PAID
COMPENSATIONSEWER-SANITARY-STORM EA 200Fr Date Recei t#
!Thio section need not becampleted Bthe permit bforone hundred dollars
(;100)mIr..) ENERGY FEE Y N
Icortifythat in the perfomvnce WATER W/VENT/ELFLTR ofthework forwhich this permit 1.issued,
I shall not employ any person In any manner so as to become subject to the
Work m'C.mprrogu n laws of CeBfomb.DateWATER SYSTEM/TREATING
PAID
Z AppileanNOTICE
OTICE NEW RESIDENTIAL PLMB. SQJIT. Date Reeei t#
Z O NOTICETO esubje subject
Bork Workermaking s'
ensationis icateof Exemption,you
should you
man subjecttothe Workers'Com provixi n sorthis permit shall
Lab or TOTAL:
� (A Code,you mustlorthwith comply with each pmvblons or this permirehall be J D G
W j deemed revoked. - FEE
CONSTRUCTION.LENDING AGENCY SEISMIC FEE
IL l hereby affirm[hat there is a construction lending agency for the perform- ELECTRIC FEE
=) Z ance of the work for which this permit b Issued(See.3097,Civ,C.) TOTAL: MR
(-) 2 Lenders Name r�kmV PLUMBING FEE
ly I- Lender.Add.m .•. MECHANICAL PERMIT FEE MECHANICAL FEE
O 111' 1certlfythatl havereadtht application and statelhattheabove Information -
IL bcorrect.I agree to comply with all city and county ordinances and state laws. PERMQLSSUANCE F[
EES
relating to building construction,and hereby authorize representatives of this I
(— Z city to enter upon the above-mentioned property for lmpection purposes., ALTER OR ADD TO MECH. Dale ReCei t#
— - (We)agree to save,IndemNfy an d keep harmless the City of Cupertino
against blllties,)odgment,costsanit 1parts..which may In anyw a AIR HANDLING UNIT(IG 10,000 GEM) - SUBTOTAL'
ago' t an' ehBperm
AIR HANDLING I1N77(OVER 10,000 CIM) CONSTRUCTION TAX
nature. AppB /Contr ctor Dat ExHAUS'rHOOD(W/DUCT) CONSTRUCTION TAX PAID:
kJAZARDOUS MATERIALS DISCLOSURE
Will the appBcontorfuture building occupant store or hand to hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the �{ �1
Health and Safety Cade Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL' yC,aCaU IJ
M Yea 1]No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air ,
Quality Management District? BOMER-COMP C3HP OR 100,000 BTU) q p I
4Yes n Na _ Y' /si
haweread Health&Safus eyCodelabrequirerrenbunder Chapter 25534. 95o( BOILER-COMP(OVER IW,000BTN
the CaliforniandtHealth the building
Code, Stela 75505,ve a tenant,
DEC O
understandhat odebuted.partnoterequirmentstenanpthatitboy NEW RESIDENTIAL MECH. SQ.Fr 1991
prior to h Wty to notify the..part cc the requirements which at be met ,
prior to issuance of Certificate of Occupancy. -
CI Y r 'l7rchHNU
Owner or authorized agent Date - TOTAL: ISSUEDBY:
OFFICE COPY