23000 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Budding Addmaildin ER Project Identification - PERMIT NO.
23000
ens aces, one:
7 G CITY OF CUPERTINO-BUILDING-DIVISION
Contra to:sName: Lk.No: APPLICATION / PERMIT
. BUILDING-ELECTRICAI PLUMBING-MECHANICAL CATEGORY CONTROL N ,
Archited/ glneer. Lie.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add. PFRFRTISSUANCE _ I�W 5 mj 1v
LICENSED CONTRACTOR'S DECLARATION L7�' L�.I fl!�44
I hereby affirm that am Bcenead under prowdons of Chapter 9(comment, APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwith Section7ODO)of DiWslon3ofthe Businessand ProfesslonsCode,and m
License is in farce and effect. PANELS �� Re
�0 � I
License Clam Lkec IA/'
Date ContractorUP TO 2DO AMPS
ARCHITECT'S DECLARATION 201-1000 AMPS
00 Zp Iundemland my piers,elul be used upub0crerorde. DYERi(1(IO AMPS ALED I g/��
k� Licensed Professional SIGNSELECTRICAL Fli
<< OWNER-BUILDER DECLARATION M P U
Z, y SPECIALCIRCUIT/MISC T E
via, owing a ..(SectLmexem fromt.rul I' mione;Code:
Any
or IX
4Z following reason.(Sealers 7015,Buslnt ck and Professlom Code:h o dty or 13/ 9 2
02-9 TEMP.METOL ORPOLE INS(. I
�0coyntywhkhrequbcsapermlc„.Iomrqudtheapmvgdemoch,or tto
q any structure tate entn that
he is lice reed pursuant
to the
provisions
of t e POWER DEVICES DATE
P�ru1 floe a ador's statement
cens eLa Mat he Ica licensed pursuant to the provblom of the —
Q63u, Con3.fthb License law(Chapter 9[,msCcmmend.Iheleng with 5ect1on7000)of errat.-
O�^ , elon3o(the Business and Pro(essbro Code)orthal hebezempttherefromend SWIMMING POOL ELECTRIC VALUATION
o the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSsSWITCHESFIXTURES -4060 O
applicant for a permit subjects the applicant to a civil penalty of not more than
five hundred dollen($SW). NEW RESIDENTIAL ELECTR SQ.FP. ES TYPE CONSTRUCTION
X, ❑i,as owner of the property,or my employees with wage.as their sok
mmpensatlon,willdothe work,and thestrucere isnot intended or offered for
Osale(Sec.70K Business and Professions Code:The Contractors License Law
$ does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP RES.UNITS
EE who drus.uch work himself or through Ma own employees,provided that such
improvements are not intended oroffemd forsale.If,howevegthebulldLeg or - TOTAL:
Improvementhaoldwithinoneyearofcomplctlo0.theawner-builderwBl have
tIB-burden of proving that he did not build or Improve for purpose otule.). QTy, PLUMBING PERMIT FEE L.J FLOOD ZONE APN
L as owner of the property,am exclusively Business
andcontracting with licensede: PERMconISSUANCE
11.Contractors
rs struct Ll..theproject( ec.70”one
to anessandofprolomCode: _0
Wil Co.,impre Llmnac Taw don not eppty ct an owner d property with
ALTER-DRAM A VENT-WATTS(EA)
Wild. or Improve thereon,and who contracts for such w.ojetts with a . FEE SUMMARY
cgp(Taaor(q gene under Sec.
to the Coneradora Llwnse C for
BACK FLOW PROTECT.DEVICE
LII am exempt under Sec B&P C (or MIs reason
. Owner Date
DRAINS FLOOR,ROOF,AREA,GOND. SANITARY Y N_ '
WORKMAN COMPENSATION DECLARATION p BBCEIPTM
❑I hereby afflrm that 1 have a certificate of consent to self-insure,ora ��P /p�QQ STOOL TAX Y_ N_
cenifimte of Worken'Comperuation lmumnmoracedifW mpythereof tSco. RECE]PT#
3800,14b C3 GAS FA.SYSTEM-1INCA OUTLETS PARKFEE Y_ N
Policy# RECEIPT N
Com ny GAS F.A.SYSTEM-OVER 4 LEA) BUILDING DIV]SION FEES
Codified ropy is heed with the
GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
Codified ropy V filed with the city WpMlon division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.Man. Dale Recei t#
(This section need not W completed If the permit isforom hundred dollars
(g1 W)or less.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I mnify that N the performarmof the work for which this permit is weed,
I shag not employ any person In any manner so as to become subod to the WATCR SYSTEM/TREATING
Workers'CgyaappeertrtN�}tion Laws of G D PAID
O Z Appucan�4 s��.i_ a. NEW RESDFNTIALPLMB. SQ 7. Date Recei t#
Z O NOTICE TO MPLICAjYI'4,aRer moving this Certlflrale of Exemption,you
should become subject to the Workers'Comperuatlon provisions,of the Labor TOTAL:
N Godly.. at forthwith comply withsuch provblonsmthb permit shall be BUILDING 'E
W 9 deemed revoked,
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Iherebyaffirm that there h m
a curs,tctlon lending agency for the pedorn, TOTAL pd ELECTRIC FEE
Z .Z
once.f the work for which thh permit is issued(Sec,30ff/,Civ.Cd ,3�x
00 Lender'.Name PLUMBING FEE OV
LL H Lredre.Addmm QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O WImdlfythatlhavereadthbapplkatbnandstamthattheabovelnformatlon
fl ismrnect.l agmtocompoy with all city and muntyondinancre and slate law. I PERMIT ISSUANCE S('b FEES PAID:
W relatingtobulldinge mtmction,and hereby authorlu representatives ofthls
cit to entero n the above-mentioned propertyfor W ion ALTER OR ADD TO MECH.
~ ? y(We)agree to save,Indemnify an d eehmless the City of Cupertino Date Recei t#
L.I .gaWt RabiBtlm,judgments,cuts...d expenses which may in anywayaccme AIR HANDLING UNIT(TO 10,ODO CFM) SUBTOTAL'
against said City In mnsequenm of the granting of this permit. fdCONSTRUCTION TAX
AIR HANDNG UNIT(OVER IO,000CFM)
Sigrature of Amit/ omractor Date D(HAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willtheappllcant or(umrcbullding occupani store or handle havnious HEATING UNIT(TO 100,000 BTU) Date RCCeI t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the p
Hee led and Safety Code ctlon 25532(s)2 HEATING UNIT(OVER 100,000 BTU) TOTAL: I_3 -
❑Yea No
Will the applicant (atom building occupant use equipment orduv_ VENTILATION FAN(SINGLE RESID) tI. SD ISSUANCE DATE
which emit havMous air contaminants as defined by the Bay Area Air
. Q11.11ty Management DisMct7, BOILER-COMPOHP OR 100,00 BTU) p AID
Yrs [�Pf.
7uvem.,Hhehazadlousmaterialsmqulmmcntsunder Chapter6.93o( BOILER-COMP(OVf12100,ODDBN)
the California Health&Safety Code,Sect ions 25505,25533 and 25534. 1 NOV 18 1991
understand that lithe building does not currently have a tenant,that It b my NEW RDENTIAL MECH SQ.Fr.
responsibility to notify the occupant of the requirements which must be met
prior to muanm of a Certificate of Occupa icy. -
cu Yr U CUPtn I INU
Owner or aulh agent Date s� ISSUEDBY:'Y, �,
TOTAL:
OFFICE COPY'