23697 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Build lag Address:o 23697
�,�,�
N..:
on.:- 1 4 one. CITY OF CUPERTINO-BUILDING DIVISION �``1 L L/
S A
Contract LIc.N.: APPLICATION / PERMIT V
Name;
Z �� BUfLDING-MECTMCALPLUMBING-MECHANICAL CATEGORY CONTROL
Architect/ gine - - LIc.No:
�(J�•� QTY ELECFRIC PERMIT FEE BUILDING PERMIT INFO
Address: — S PIRMITISSUANCE
ISz
LIC ENSEDCONTRACTOR'S DECLARATION E
I herebyaffcmthat l amlicensed under provisionsodChapterg(commmu, APPLIANCES RESIDENfIAL OB DFSC OiiM..111���
ingweh I.hill
to.
efeion3o(the Butlriasand ProlesslonsCode,aced my law*
�a ti \�
license!Class rani and effect. PANELS '✓iw* pew
License Class LkN
' Data C.ntnct.r UPT0200ANTS ,
ARCHITECT'S DECLARATION 201-I00OAMPS
pQ±Q CCQ IuMr bind myptmahaubeused aspubllcrecords. OVER1000AMPS YQ.FT.FLOOR AREA 5/�.n
E d Gcenecd PrcdmI.ml §G
- OWNER-BUILDER DECLARATION L /
Z s,E^31 I herebya(flrmthal I am exempt from the Contractor's License Law for the
following reason.($onion 70115,Business and Profenbm Code:My tlty or I'
Kf• countywhlch requlreaa pemJtromrutruct,alter,improve,demolish,orrepalr
Ianys'ructure pri.rto its Issuance,also requlresthe appgontfor such permit to POWER DEVICES
(� Ile a signed statement that he t licensed pursuant to the provisions of the
0 t� Contractor's License Law(Chapter9(commencing with Section 7000)of Di
vl- VALUASGN�
1, 5 shoo 3o the Bustessand Prolealom Code).,that hebe emp the c(mmaon VV I`—//
•I the bash for the alleged exemption. My violation or Section 70)15 by any ^
6S appra.-I orapermta bjmutheappUcanttoadvilpevityanom m ban OVILETSSWIT'CHESFf%IVRFS `
115undreddoltreaSM. -
I,asowneroftheproperty, NEW RESIDENTIAL ELECTRSQFf. STORIES TYPE CONSTRUCTION
O�n ,a or my employees inwithwages r their mm(Sce,7.n,Businesswill do work,sessions Code:Ttoottrended or offered Law
sacs not apply to an owner
mif property Code:The or improContractoves
LlcemeTaw
doesnessucot y loan.waelf ofplf ropertywhonemporlmproveslhereoRand that such OCC.GROUP RFS.UNITS
whodvessuch are not meededorougb his or own oweyees,providedhe ilding or
Improvements sold ithiIntenoneyerofco pletio.the owevep deer ill have TOTAL:
Improvement teokiwlthlnoneyearofcompinlorytheowner-budderwillhave
tliLliurden of proving that he did not build or improve for purpose of ule.), QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
U L as owner of the property,am exclusively contracting with licensed
contractors to construct the project(Sm 7094,Business and Professions Code: PERMIT ISSUANCE
The Contractor.License law don not apply to an owner of property who ALTER-DRAIN kVENT-WATER(EIV
Wilds or Improves thereon, and who contacts for such ppojects with a
cgB((actor(s)licensed Pursuant to the Commerce's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
L I am exempt under Sr. R h P C for this reasonOUTSIDE FEES
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
• Date RECEOrT N
WORKMAN COMPENSATION DECLARATION
�PER.�P SCHOOLTAX Y_ N_
❑I hereby affirm'hat 1 have o lrtsane of consent to pythemof ora ROCFL'T N
3800,mdiflabC.Worken'Compematlonlmurance ora cartlfkd mpythereo((Sec. GAS EA,SYSTEM-1 INCA OUTLETS PARK FEE Y N
Poli3800,Lab C.)
Comcyan GAS EA.9YSnM-0VER4(EA) DING 'Ip
Y BUILDING DIVISION FEES
CenlRed ropy t heed with the nished.
GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CertUed copy t(Icd with the city Impenl.n division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-gAM.I.ARY-yTORM EA 200HT. Date RCCCI tN
(TMssenion need not be completed tithe permit t forone hundred dollars
(y100)orless) WATER HEATER W/VENT/F2.ECTR ENERGY FEE Y N
I cartilythat In the performance ofthewwk rarwhIch this permit is Issued, —
I shall net employ Any Person In any manner se as to become subject to the WATER SYSTEM/TRGTING
Workers'Compensation Laws or Callfornt..Date PAID
O Z 'Applicant T:HNEW RESIDENTIAL I'I.MB. SQ.FI'. Date Recei tq
Z O NOTICE TO APPLICAN ,after making this Certificate of Exemption,you
Fshould become subFct to the Workers'Compensation provtlomolthe Labor TOTAL'
N Code,you most forthwith comply with such provisions,ortht permit shall be
7 deemed revoked. BUILDING FEE
OG CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby afprmthat there t a construction lending agency for the perform- ELECTRIC FEE
7 Z arm of the work for which this permit t Issued(Sc.3097,Civ.Q T �_
U O Lender's Name PLUMBING FEE
LL F Lender's Address - QTY. MECHANICAL PERMIT ME MECHANICAL PEE
O,W rrIrimifythst I haveread this application and statethatlhe above information
IL "coect l agree to comply with all city and county ordlnanen and state laws PERMIT ISSUANCE FEES PAID:
T IL relating to Wilding romtroctioryand hereby.whmlu representatives ofthis
F city to enter upon the above,mentioned property for inspection purposes. ALTERORADDTOMECH.
Z
Z (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Recei t>f
agairlar liabilities,to mens,costsA expenen which may In anywaya.. AIR HANDLING UNIT 10,000 CFM) SUBTOTAL:
al tsald Cltyin Qme sae sof grantingoftht permit.
g_(Z; AIRHY,NDLING UNIT(OVERI0,000CFM) CONSTRUCTION TAX
Signs reof Applicant/ .mract D TAI to DQIAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or hand to hazardous HEATING UNIT(70 100,000 BID) Date Recel
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 23532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTiMC`
❑Y. No
Will theapplicant erTr tum building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Arca Air
Qua Oty Management District? BOILER-COMP(3HP OR 100,IXq BTU) P
4Y. ❑❑Na E
have read the hazad.uemaleaLrequlremonlunderChapter 6.95o! BO LFR-COMP(OVQt100,D00BTp
the Califomt HealthASfdy Code,fedt m25505,25533and25534.I
understand that lithe building does not currently have a tenant,that It t my NEW RESIDENTIAL MECH, SQFI MAY 1 $ 19_
resp.rulbllily to notify the occupant of the requirements
which=at be mel
prior to Issuance of a Certificate or Occupancy.
till
Owner or authortred.gem Data TOTAL] ISSUED BY:
OFFICE COPY