23764 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm'ed identification PER,WT NO.
Building Address: �3 I- 23764
n
wone: A A
'�0 CITY OF CUPERTINO-BUILDING DIVISION
contraoral`''/y.R� ,SC t lc.No: APPLICATION EPER IT � � Z
L-�r v` 1 BUILDINGELECTRICALI'LUMBINGM CAL CATpLORY CONTROL#
ArcMtrct/Engineer. Lk.No:
Q1Y ELECTRIC P R FEE BUILDING PERMIT INFO
Addrcs
PERMITISSUAN E El ElLICF.NS ED CONTRACTOR'S DECLARATION
I hereby affimnthat lam licensed! ov
under prisions of Cha pier 9(mmm
mc AN FS NTIAL )Oil DESCKLirl ION
Ing with Section 7000)of Division 3 ofthe Busimasand Profood...Code,and m
license isIn full and effect. P
LI...Cl — Lk.#_3 5-1 -10 LJ jp� -
Date 7 Contractor PyriU9Y.4lRX)AMPA 1, 11
ARCHTEC7PS DECLARATION 4000 AM
2 Iu Qers'aand my
wds. OV 1st r $/ Ff
tpe �R ;iZ Professional l c SIGNSE a:PC�
6 OWNER-BUILDER DECLARATION SI+ECIALCDICNT/#LSC
71.., 'y ]hereby afflrm that]atm exemptfromthe Contractors Lkenv law for the
following reason.(Section 7a)1S,Businessand Professions Code:Any dty or
O�lp"'u9 cwntywhlchrequlresaper tit mt d,alter,improve,dennlish,orrepair TQdP.METFlZ OR POLE INST.
anystrunure prior to its ftsuance,alsorequires theapplinnt forsuch permit In
POWER DEVICES ,
6 Gc7 file a signed statement that he b Bacardi pursuant to the pmvbkv of the
Ow Contractors Liceme,Low(Chapler9(mmmencingwlthSwam 7000)ofDivl-
302' son 3ofthe Business and PromassionsCods)orthat heis exempt therefromand SWIMMING POOL ELECTRIC VALU TION
the basis for the alleged exemption. Any violation of Section 7011.5 by say O OUTLETSSWITCHESFlXTURES Z
aPphomt for.permit subjects the applicant to a civil penalty of not more than
fivc huselrod dollars($500). Ol I OL
NEW RESIDENTIAL ELECTR
.. [fT,pe saowner of theproperty,or my employeeswith wages r offered
sole �'�' STOW TYf+E CONSTRUCTION
� G compeneatlmn,wWdotM work and the structure isnot Intended or o(femdfor
/�L'
Fall A
J O vie ISM 7044,Business and I'mmasions Code:The Contractor.Llacto Lew L 1
61$S docs not apply to an owner of property who Wilds or Improves thereon,and O NGS .UNITS
GG who does such work himself orthr°ugh his own employees,provided that such
improvements are not intended or offered for sale.If,however,the Wilding or T
Improvement issold within one yearofcompletlon,the owner-Wild erwill have �
tr rdenof provingthat he did not build or Improve for purpose ofsale.). QTy. PLUMBING PERMIT MTSI APN
L as owner of the pmperty,am exclusively contract...with 1—n—
contractma toconstrud the project(Sec.704y Businessand Professore Code: PERMITLSSUANCE
ass
The Cont moors License law does not apply to an owner of property who ALTER-DRAIN&VENT.WATER(EA)
Wilds or improves thereon, and who contracts for such pkopcts with a
o trachm(.$)licensed pursuant to the Contractors License Law. BACK FLAW PROTECT.DEVICE FEE SUMMARY
I am exempt under Sec B &P C for this reason
Ow c ILS D S L DRAINS FLOOR ROOF,AREA,COND. SANTARY Y— N_
RECEIPT PT N
'WORKMAN COMPEN TION DECLA ATI N pDTNRFS PER TRAP' SCI{OOL TAX Y N—
❑I hereby affirm that I have o cortin nc of consent m opytneure,ora RECEPf N
cenifi"bC.Workers Compensatlonlnsunnm oracertlfied ropythemof(Sec. GAS FA.SYSTEM-I INCAOUTLETS PARK IEE Y N
3800,Isis C.)
Policy N RECEIPT N
Com any
GAS EA.SYSIl]N-0VER4(EA)
MCertified copy is hereby furnished. BUILDING DIVISION FEES
❑Certified copy is filed with the city bupection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASETRAP - PAID
QM1 ,qo
COMPENSATION INSURANCE - SEWER SANTTARYSIORM EA HIOFT Date ReCCI tq
sse<tlon need statmbeW comcmmpldN tithe permit is ne(Drohundred dollars
x100)°rlyth WATER HEATER W/VFNT/ELECTR ENERGYFEE Y N
Illnot employ
by person to any thewmk(orwMch this pemnkis issued, —
1 or stat employ any person In any manner oto to co wbject to the
Worken'Co vtlon laws (Cal mla.Date•1" v W'AT°l�" M/TREATING PAID
O Z Appucanp �� —
Z O NOTICE TO,YPPLICANT:IL aker makla is Certs late of Eaemption,you NEW RESIDENTIAL PLM6. SQFT. Date Recei t#
Fshould become subject to the Workers'Comperaation provisions of the Labor TO AL:
X W Code,you=at(on hwith comply with such pmvisions or this permit shall be
W > deemed revoked. B IL TNG[TE
a p CONSTRUCTION LENDING AGENCY SEISMIC FEE
- I hereby atnrm that there is a corotrodion lending agency for the perform- ELECTRIC FEE
Z anceof the worktor which this Ferman es tcwed(See.3097,Civ.C) TOTAL:
U O le.der'BName PLUMBING FEE
LL ~ MndersAddrens QTY. MECHANICAL PERMIT FEE d MECHANICAL FEE
O W certify thatl have read thisappgotion and statethatthe above information
bc.rredl agree to comply with all dtyand county ordinances and state laws PERMTTISSUANCE FEES PAID:
} Wrelating to building construction,and hereby authorize representatives of this
F Z city to enter upon the above-mentioned property for Wpeetion purposes. ALTER OR ADDTO MECH.
— (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receiptll
against liabilities,1udgments,consand expense.which may in ayaccrue AIR HANDLING UNIT(TO 10,M0 CPM) SUBTOTAL,
against said Clt conaequenn ftheanting at this permit.
'tui V Y AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
SI sure. ppu..,,Contractora EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOS E
Will the applicant orfown,building occupant store or handle hazardous HFATINGUNTT(TO 100,0DOBTU)
moteriala.deMed by the Cupertino Municipal Code,Chapter 9.1$andthe Date Recel t#
Ilealth and Safety Code Sed.on25532(a)7 KEATING UNIT(OVER 100,000 BTU)
❑yea TO
h
No
Will the appiiant o future Wilding occupant use equipment or devices VENTILATION FAN(SINGLE BERM ISSUANCE DATE
which emit hazardous air contaminants as def.ned by the Bay Area Air
Qat Pity Maw gement Dist ct7 BOILER-COMP OI-B'DRI00,000 BTI!) r
4 yes Mo pa Na
havercad teeth mode, cOl.hareme.tsunder Chapter of BOILER-COMP 1(D,Ofp BTU) B— V
the California Health&Sa(dy Code,Sections 2550.5,25533 and 255#. I
understand that if the building does not arrently have.tenant,that it is my NEW RESIDENTIAL MECHL SQFI.
raponslbilityto na./ythe Deco .t.f the mquimmehav,hich must be met JUN �� s
prior to uance ofa Ce fic o(Occvparcy 1� s
4 y �'' YY//�I���s�
rrorauthorized agent at TOTAL: ISSUED DY: .IIS N7SFl-"LzII
Vl��
OFFICE COPY