23635 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Pro ea Identification
Building Address: Q
- PERMIT NO.
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G 6 05 S CITY OF CUPERTINO-BUILDINGDIVISION r�
uc.N°° APPLICATION / PERMIT
'
rchlteci/Engineer. BUILDLNGELECnUCAI PLUMBING-MECHANICAL CATEGORY
Lie.No: CONTROL p
QTY ELECTRI,C PERMIT FEE BUILDING PERMIT INFO
Address:
PERMIT ISSUANCE O ❑
'LICENSED CONTRACTOR'S DECLARATION
[hereby af(irm[hatlam 8cxn.ed underprovWonso(Chapter9(comment- APPLIANCESRE4IDENTIAL ]Og DESCRR'fION
ingwlthSecil°n7000)o(DlWalon3o(the Buslnessand ProfesslonsCode,and my
I license Ifu
s n g to aneffect /a Q �� PANELS
If CI d
Lic.p O I W
Date Contrador - r
RCHHECPS DECLARATION 201-1000 AMP$
rrps2. [understand my plans slug be used as pu68crecoNs. OV;IAMPS - SQ.IT.FLOOR AREA ($/SQ.r5LicensedProfee.ional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATIONSPECIAL CIl2CUIT/MLSCqI hereby affirm that l con exempt from the Contractor's License Law fw the p following reason.(Section 7031.5,Business and Prefesebns Code:Any city orLRM !y c°untywhlchrequlreaaPermitromrutmMalter,Impmve,de=lWhorrepair TEMP.METER ORPOLE WST. / ���� ,.—
anystruature priortoltslssuance,also requireathe appHeantfwavahpermittoPOWER DEVICES � ��L.JI'�0file a signed statement that he b gcenaed pursuant to the provlate m of the3wContractors License Law(Chapter 9(commencing with Section 7000)of Divi-
eion3oftheBuslnesa.ndPmfeaeioruCode)orthatheisexempttherefromand SWIMMING POOL ELECTRIC L' V LSAffTM
'� by any OUTLETSSWITCHESFIXTURFS �� e/'�""0 appllcantfora permit eubjeRethe appilcant toativll pemlty of not more than J' r
five hundred dollars(8500),
I,as owner of the ro my p oy g NEW RESIDENTIAL ELECTR SQ.FT, TYPE CONSTRUCTION
�n ❑ p petty,or em 1 ees with wa ee ea their sole STORIES
compensation,wllldotM wwk andtheetmciure lanotlMeMed or offered(or ,
sale($cc.7094 Buelnens and Profembru Code:The Contracior'e Licewe Law
does not apply t°an owner of property what builds or Improves thereon,and
whodcessuchwarkhimaelfwthrwgh hleownemplayees,provided[hatsuch OCC•GROOP RES.UMTS
improvements are not intended oro((ered(or Bale.If,however,thebullding or TOTAL:
Improvemen[leeold w)thlnoneyearofcompletbrythe owner-bugderwlllhave
tte�urden ofpmving that he dW nw bund orimpmve tw p°rpoae ofsale.), QTY PLUMBING PERMIT � FEE
LJ I,as owner of the property,am excluelvely contracting with licensed FLOOD 7ANE APN
rontractors to corwlruat the projeci(Sec,70948usinees and Professions Code: PERMIT NUANCE
The Contractors Li nee Lew does me apply to an owner,of property who '
bagda or Improves thereory and,who mntraM for
each plojecia with a ALTER-DRAIN VENT-WATER(EA)
on cter(a)licensed Pursuant to the Contradoes License Law. - FEE SUMMARY
L�I am exempt under Sec B&P C for this reason BACK FLOW PROTECT.DEVICE
Owner Date DRAINS.FLOOR,ROOF,AREA,COMJ, SANITARY Y' N
WORKMAN COMPENSATION DECLARATION RECEIPT N
], ❑/hereby ef(Irm that I have a mrtlRcate,of consent to.elf-Insure,or. FIXTURES PER TRAP SCHOOL TAX Y N
39W,certlflUb C.Worken'ComperwHonlrauranaora certifted ropythereof(Sec. RECEIPT#
Policyab CJ GAS EA,SYSIFM-1 WC.40i1TLET5 r PARKFEE Y_ N_
Policy X .RECEB'T X
Com any GAS F.A.SYSTEM-0VER4(EA) BUILDING DIVISION FEES
' �Certl(led ropy he hereby famished.
Certified copy las filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP' PAID .
COMPENSATION INSURANCE
(Thksardlonneed net becompiated Bthepermit laferone hundreddollare SEWER-SANHARY-STORM EA.2001717. Date Recti t#
(810()w lese.)
I mrtifythat In the Performance ofthe wwk forwhich this permit is Weed, WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
I.hall not empi°y any person In any manner ro u be me b'tl to the
Workers'Com n Hon Le of fornV Date WATER SYSTEM/TREATING PAID
O Z Applicant LrAQ
Z O NOTTCE TO ,ICA :X-fir mmakingthle entiflute of emIn bn,you NEW RESIDENTIAL PLMg. SQ,FG De1C R2ce1 f#
N should become subject tothe Workers''Cmepematlon Pro visions ofthe Labor - TOTAL:
Codi,, moatforthwith comply with such provisions or this permit shall be
W > dmmed revokes. - B ILDI G
EL CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm Nat there is.constru tion lending agency forthe perform,: ELECTRIC FEE
M O anceofthe work f°rwhlch this permit is bsued(See 3W7,CIv.C.) - TOTAL:
fJ _ Lenders Maine - - PLUMBING FEE
ly H lendereAddreeaQ1Y. MECHANICAL PERMIT FEE
(] W Icertlfythatl have mad thsappliestom.nd statethatthogevemfroation MECHANICAL FEE
11 Iscmmd,Iagree to comply withal!eltyand countyordinances and nate laws PERMITISSUANCE FEES PAID:
W relatingtobuilding com uction,and herebyauthoriie representatives ofthls
ti Z city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
(We)agree to save,indemnify an d keep harMees the City of Cupertino Date Receipt#
againstllabllltLre,pdgmenm,mrtsendexpenseswhichmeyinanywayaccrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:age Wtcald ityimmr.eryen ofth�granting of this permit -
AIR HANDLING UNIT(OVER Ig000CFM) CONSTRUCTION TAX
Signe,ftfieof Applicant/Contractor Dat EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: '
HAZARDOUS MATERIALS DISCLO URE '
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date _ Recel t#,
HealthSafe
ty Code Seecilon2S532(e)2 HEATING UNIT(OVER 100,000 BTU)
as �No TOTAL:o
11 ly Y - - .,
Ill the applicant, future building ocmpantuse equipment or devices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air.
Quality Management D�vMct7 . BOILER-COMP OHP OR 100,000 BTU) 1�rp ' pt,
tv'?have
pp No. P PY Y .
have readthe hazar`/i oua terlab requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
:ne California Health&Safety Code,Sections 25505,25533 and 25534.1
'understand that if the building does not currently have a tenant,that It is my NEWRESIDDIMALMECH._SQFr, 7 1Q92
responsibility to net the occupant of the requirements which must be met ° a v007
prior to Wuance of a Cert(im[e o cop�, '
CITY Ur vurr-m IfivQ
Own rauthortzea agent Dat .,. TOTAL: - ISSUED BYS_�/"
se
r_ \ OFFICE COPY