23860 (2) IirrLIGAN 1 10 FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project ldentlflcatl.n PETLWT NO,
B°"'"sem 3 23860
n . - one:
CITY OF CUPERTINO-BUILDING DIVISION !"f
c tract Name: IIc.N.: _ APPLICATION /PERMIT
C/
Za `� BUILDING-ELECTMCAI PLUMBINGMFCHANICAL CATEGORY CONTROL N
Architect/Fsgirieert. Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: 131,04U hlDLI PLUMB ml,�"
PERMITISSUANCE 1:1 1:11:1LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm that l am licensed under provhloneof Chapmr9(commenc APPLIANCES-RESIDENTIAL JOB DISC ON
Ingwlthg dfon7000)of Divieion3ofthe Bueineaand PmfealoneCode,and my
license lPANELS
-ln(u (ars and d(ed. 1MTO2
Limn Iris Lkec o7 •S
Dale Conhactor
ARCHITECT'S DECLARATION 20I-I(XOAMPS
q�u CM X 16 my phns shall be used es public remrde OVER 1000 AMPS SQ.FT.FLOOR AREA $/9Q.Fr.
6i Licensed Professional SIGNS ELECTRICAL
GGGG
OWNER-BUILDER DECLARATION SI+ECIpLCIRCUIT/MISC
2 I hereby affirm that ism exempt from the Contractor's License law for the
pp following reason.(Section 70'31.5,Business and Professions Code:An tl r
Oz y city '
Kcountywhkh rcqubesapermit to mralmd,alter,improve,demolish,.,repair TEMP.-METIER OR POLE INST.
anystrudure prlorto its bauance,atsorequbeethe applicant for such permit to POWER DEVICES P e n
file a signed statement that he h licensed pursuant to the provisions of the _
O Q� Contractor's License Law(Chapter 9 icc.i drag with Section 7000)of Divi. UA ON
slon3 ofthe Bualnessand Profeeslens CodO.,that he hexempt therefromand SWIMMING POOL ELECTRIC
< the basisfor the alleged exemption. Any violation of Section 70315 by any OUTLETSSWIT'CHESFIXTURES
a Ppllciniforapem t=bjmUtheappReanttoadWipe.Ity ofmat marethan
five I,as
owndoler
ars of
epro NEW RESIDENTIAL ELECTR / TYPE GDNSIROGTIDN
�n ❑I,as owner of the property,or my employees with wages r thele dole
<
compensation.7KBuldo the ess and rkfeashmand the dwdurehrC Wended.License
d for Law
❑
sale(Sec. pply to Business Pro(eskns Code:Thebuild&or Improves
License Law
$ does not apply loan ownerdproperty hao emporlmproovidedthatsuh OCC.GROUP REB.UNITS
who dmsuch
ents am khimxUodorough Mdow sale.IL
onsveprovidedilding or
improvementsaredo Intended.,.(fendfor mals.14howeveg ilderwdingve TOTAL:
Improvement hsoW within oreyearo(compldi.rylheowner-bulWerwlll have
tkLJIurden of pmving that he did not build or improve for purpose of We.). QTY. PLUMBING PERMIT FEE FLOOD TONE APN
L j L as owner of the property,am exclusively contracting with licensed PERMIT NUANCE
contractors to construct the project(Sac.70K Budnea and Pr f.iaru Cade:
The Conto does License Law dm out apply to an owner a property who ALTER-DRAIN k VENT-WATER Q?A)
Wilds or impves eod -
rothern,and who contracts for such p(oje
s with a FEE SUMMARY
cgRtlador )Rtod
smand pursuant the Contraoes License Law. BACK FLOW PROTECT.DEVICE
1 am caempt under Sec B k P C for this reawn
Owner pne DRAINS-FLOOR ROOF,AREA,CONED. SANITARY Y_ N_
WORgNAN COMPENSATION DECLARATION RECEIPTNN
I hereby affirm that I have a certificate of consent to self-insure,or a FIXTURES.PER Tom' SCHOOL TAX Y_ N_
srt icam of Workers'Compensation Insurance or a srtlfkd copy thereof(Sec. RECEIPT
3800,Lab C. GAS FA.SYSITM-1 INCA OUTLETS PARK FEE Y N_ _
Polk),If 7 .�' RECEB'T N
TT GAS FA.SYSTFAfAVER l(EA)
Cam env BUILDING DIVISION FEES
Certl�e copy filed
the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CertBied ropy h flied with the tlty Inspection division.
CERTIFICATE OF ENEMPTION FROM WORRIES' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-SIDRM EA 200FT Date Reoei t#
Rhia section need not tr completed the permit hforons hundred dollen
(SIOO)orleseJ WATER HEATER W/VENT/EI.ECTR ENERGYFEE Y N
I certify that In the performance of the work forwhich this permit is hsued,
I shall not employ any person In any manner as as to become subject to the WATER SYSTEM/TREATING
Workers'Ccmpenatbn Laws.(California.Date PAID
O Z NOTICApplicaE NEW RISIDENITAL PL.MB. SQ.FT. Date Rete1 t#
Z O NOTICE TO APPLICANT:$after mating this Certificate o(Ezem)aian,you
Fshould become subject to the Workers''Comperuation provisions of the Labor - TOTAL:
CC N Code,yoamustf.rthwilhcomplywltheuchpmvi$W..,thhpermltehallbe BUILDING
W C deemed revoked,
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d Ihereby affirm that there h a mratrudlon lending agency for the perform- TOTAL: ELECTRIC FEE
7 Z anmof the work I.,which this permit is Issued(Sec.3097,Civ.C.) zs
U O Lender.Name PLUMBING FEE
LL F Lendeea Addtea QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W h Icertilythatl have madthis appllsvelnf
Hmand statethattheabo .rmatlon
correct.Iagree to comply with all city and countyordinanees and state laws PERMIT ISSUANCE FEES PAID:
>. 1 relating to building construction,and hereby authobm represenutives of this
N 2 city to enter upon the above-mentioned property for InspoUon purposes. ALTER OR ADD TO MSCH.
— (We)agree to ave,Indemnify an d ksp harmless the City of Cu pertlw Date Receipt#
against Liabilities, costs and expenses which may in any way ancue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL'
saga Inst said City In consequence of the granting of this permit.
AIR HANDLING UNIT(OVER IQ000 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAIM
HAZARDOUS MATERIALS DISCLOSURE EJ
Will the applicant orfuture building occupant store or handle haeardous HEATING UNIT(TO 100,000 BTI) Date Recei t#
material as defined by the Cupertino Municipal Cade,Chapter 9.1 7,and the
Health and Safety Code Section 25531.)? HEATING UNIT(OVER 100,000 BTL!) TO
❑Yes 1rr��1 No
Wlllthe appBcaor.,future building occupant use equipment or devils VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hazardous ale contaminant...defined by the Bay Area Air
Qu Iity Management District? BOILER-COMP OHP OR 100,000 BTU) -
❑Yee F1No
Ihavc read the hazardous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) A p�
the California Health k Safety Code,Sections 15505,25533 and 75534.1 Pi L
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT
resporaibllity to notify the occupant of the requirements which must be,retJUL 16^ 19
rto Lcsuance cats Certlfka of cup dt::A I 9Z auxK117"
u
net or authorized agent Data - CII 1 II
TOTAL: ISSUED BY: I .T IIYV
OFFICE COPY