23791 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY '
-Building Project Identification PERMIT NO.
Budding Addreea: ol� Ci�•�-Q-Is sL IV. 1,/ - 23791
are one
m •99r,� X55-5 CITY OF -UPERTINO BUILDING ]VISION
• cn d19L10 S �/ "e'No`0? IS APPLICATION I E IT L '
� ArcMted�((Englaer. Ll7, BURRING-ELECTRICALPLUM MECHANICAL CATEGORY C
WIII' � x-{ Ib ARCfm Tea 3 BUILDING PERMIT INFO
�^' QTY ELECTRI PE TT FEE
Address: l:l�'J t_ ,v PERMITISSUAN � mil
LICENSED CONTRACTOR'S DECLARATION �J
]hereby affirm that l am licensed under provWons of Chapter9(mmmen APPLIANC ENTIAL rpBD ON
ingwith Sadlon7000)of DlWdon3o(lhe Budassand Pro(esstoneCode,and my 6
license le In fou force and offect. - P
License Chss Llea
Date Contractor
CH CLA IONI AbOAMPS
0$ Iun� I 5 ei beu ��Ib remrda ]OW AMPS -SQ:j� 7 -FT.
�() LI se nmfesslon NSEL
<FkA+ R-BNLDERDECLARATION SI•fCIA MLSC_ \
s., .711 Iherebya(fl tram exemptfromthe Camrador's License law(or the
Zp folbwing reason.($ecNa 70315,Business and Professions Code:M ci or
TEMP.M rLEINn
P� county which requires a permlttecom uct,alter,improve,demolish,or repair
q anystructure prbrto lb Wuaae,aleo requlrmtherppBcentfor such pemdt to p04yERD CES
P+�w Ble a signed statement that he In llnneed pursuant to the provisions of the
Q6 3 u, Contractors License Law(Chapter 9(commencing with Section 7000)of Dlvi-
O In SMMMINC POOL ELECTRIC
Ionlof,he Busines3"dPrfmss mCodelorlhathol3exempt,hemlmmaM VALUATIONssO
the basis for the alleged exemption. Any violation of Section 70115 by any OUILE3S4WITCHES D(I.URES71
VV�.n
06 appumntfora permit subjects the applicant to a civil penalty of not mon than J`
five E]1,asmwnerof thepr. SQ STORIES TYPE CONSTRUCTION
t"u NEW RESIDENTIAL ELECIR FI.
�n ❑!,nowaroftheproperty,orha employees 1nwithwagm as their sole
CC G sale&c.Bory Business and
Prefos theaC de:Te Contractorot or..Led for
'1 $' O sale&c. to alnower of property
Code:The Contractors Llamelad
$ ciao esn'such apply torn owner ofpmpghhiso nemuilds orlmprwnted thaton,such —and OCC.GROUP RES.UNITS
whodoementsw norintededolf rwferedowne.If,hoeeprovidedilding or
improvementsarenot Intended earofco morale.It, wner-p lklerhe buildingor
improvement bwldwlthlneayearof<ompletiogtheowner-bullderwill have
ten of proving that he did-nmbulldorbnproveforpurposeofsale.k QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
UL as owner of the property,am exclusively contracting with licensed
controon to construct the project(Sec.7074,Bush=and Professions Code: PERMIT ISSUANCE
d
The Contractor's License law does not apply W an owner of property who ALTER-DRAW&VENT-WATER MAI
builds or Improves thereon,and who contra for such projects with aFEE SUMMARY
C1511
R(faso
ctor(e)licensed pursuant to the Contractors Lime. BACK FLOW PROTECT.DEVICE
L�I am exempt under Sec. B&P C for this rean
DRAINS FLOOR ROOF,AREA,GONG. SANITARY Y N
Owner Date RECEIPT 0
WORKMAN COMPENSATION DECLARATION IRI(TIRtES PER TRAP SCHOOL TAX Y_ N_.
QI herebbyy rffbm that I have a certificate of consent to self-inerre,ora
CRECEIPT Y
ce00,Laeo(Workeri omperuatlonlruuranceorrcertifled copythemof(Sec, GAS EA.SYSTEM-1 WCAOUTLEIS PARK FEE Y N
3800,Lab CJ
Poll R RECEGAS EA.SYSTEM-OVER 4(EA) DINT DIVISION
Cam any BUILDIN DIVISION FEES
[(Certified copy he hereby furnished. GREASE/WDDBTRL WASTE INTERCEPTOR PLANCHE F
F]Certlfied copy b filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAI
COMPENSATION INSURANCE
(Thin sedion need nor be completed if the permit Is for one SEWER-SANITARY hundred dollars STORM EA.2l10FT. to R.
(5100)wly that
WATER HEATER W/VENT/FLECTR - E FEE _ {! �—
Icertuythat(.the performance ofthe wmkfor wNchthis permit is issued,,
-50
I shall not employ any person in any manner so as to become subject to the WATER SYSITM/TREATING
Wmken'Compenuuonlawsof CaWomh.Data
PAID
0 Z Applicant NEW RESIDENTIAL]'LMB. SQFf. Date tic
Z O NOTICE TO APPLICANT:If,after raking this Certificate of Exemption,you
should become subject to the Worken'Compematlon provisions ohhe Labor TO L-
Ol Cade,you at forthwith comply with such provisions or this permit shall be
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a I hereby affirm that there b a co.tmetion lending agency for the perform- ELL•CTRIC
Z anco of the work for which this permit b issued&S 3097,Civ.C.)
02 (ander'.Name PLUMB]
LL F- Lender.Address QTY. MECHANICAL PERMIT FEE MEC a^
OW I certify that l have med this application and nate that theabove information
C Iscomat.Iagreetocomplywithallcityandcountyominanananddatelaws PERMITLSSUANCE F E$ D.
>. W relating to building construction,and hereby authorlu representatives m thio
f. Z city to enter upon the abov nxntkmxcl property for lmpedion purposes, ALTER OR ADD TO MECH. to Receip[M
— (We)agree to save,IndemNfy an d keep harmless the City of Cupertino
agalnt liabilities,Judgments,codsand expenses which cosy In anywayacaue AIR HANDLING UNIT 8010,000 CFM) SUBTOTAL•
t a aid City In cons n the granting of thispermlt 7—.L-9z—
_ AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRU ONTAX
Sig re of Applicant/Contractor Date Z EXHAUST HOOD(W/DUCT) CONSTRU ON TAX PAID:
HAZAR DOUS MATERIALS DIS RE
WIII the appBont orfuture building occupant atom or hand le hazardous HEATING UNIT(TO 100,000 BM Date Recel til
77:2111 as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Stolon 25532(.)7. HEATING UNIT(OVER 100,000 BTU) TOT
11�11 Yes No
CE DATE
TV lllthezppllcanta lurebullding.pantu.e quipmentordevi.a VENTILATION FAN(SINGLE RESID) IS$UA
which emit hammnus ab contandmnb as defined by the Bay Arca Air
' a Ilty Management Detrict2 BOILER-COMPOEIPOR100,000BTU)
Yearead ❑No
havethe hara2usmaterials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) P A I,D
the California Health&Safety Code,Sectio.25505,2W3 and 25517.1
understand that if the building does not currently have a tenant,that It is my' NEWRESIDENTIAL MECH. SQET
responsibility notiofa the occupant Ocupancqulrcmenla which must be met rJR i 2
prior to Issuance a(a Ce2lfiole of Occupancy. (((((
• rLTll IIYV
Owner or authorised agent Data IS$[RiDB
OFFICE COPY
/