23723 (2) AFFLIGANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project ldentlflodon
Building Address: PERFDT NO.
1405 �I b�S��S 23723
mars eros: ..AA Phone:
F v 7.39``iT 7 CITY OF CUPERTINO-BUILDING DIVISION .� Z
C It`ror',N1tL�a'�f7 Lic.No: APPLICATION /PERMIT
Architect/Englreer: BU[LDINGELECTRICALPLU HING-MECHANICAL CATEGORY CONTROL p
Lk.Na
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
naarcn:
PERMIT ISSUANCE �^ t
LICENSED CONTRACTOR'S DECLARATION
I herebyaffirmthat l am licensed under provisions of Chapter9(commenc- AI'PLIANCESRES[DENTTAL JOB DESCREr170N
LyP
Ingwith Section 7000)-f DiWa on3 afthe Buainenand Pmfessiona Coda and my
lienee[Class orce and effect. pgNrp�c S ?s1�2
License Clan Lisp
Date Contractor
ARCHITECTS DECLARATION 201-1000AM
rt OCCp0 I understand my plans shall be used as public records. OVER7000Lj SQ.FI FLOOR AREA S/SQ FI.
Licensed Professional SIGNS ELEC L I -
f OWNER-BUILDER DECLARATION
I hemb affirm that Iam exemptlromthe Contractors License Law f-rthe SPECIALCEtCUIT MISC ••� 1
following reason.(Section 7MI.S,Business and Profession Code:Any ctty or
P4 cauntywhich requires a permitmcommtruct,alter,improve,demolish,orrepair TEMP.METER OR POLE '
O ¢ any structure prior to its Issuance,also requires the applicant for such permit to
V file a signed statement that he is licensed pursuant to the prootaiom of the POWER DEVICES
3 40 C-ntractots License Law(Chapter 9(commencing with Section 7000)of Divi.
GS sion 3 ofthe Business and Profenimu Code)or that he is exempt therefromand SWIMMING POOL ELECTRIC VALUATI(]�{�.x
the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCIiESFIXTURES <_Js"�
O pplicentforaper isubjectstheapplicanitoapivilpeaityaf o =mthan 1 Soo
C. $ v undred dollars ISS00).
ae owner wilof the property,or my employees with wa es as the'
sole NEW RESIDENTIAL ELECTR SQ.FI. STORIES
YI' 6 TYPE CONSTRUCTION
pensadory B"I Bothe work and theatmature Isnot Intended or of(eretl(or
D nM(Sec.7654,8usinen and Pro(eni-mu Code:The Coatrector Llceme Law
F $ dcea not apply to an owner pro
who builds or Ion mveathereon,and
who doeesuch workhimsel(-rthraugh his awn employ wait or
OCC.GROUT' RES.UNIT'S
Improvememus not intended proffered f-reale.](however,the buildingor
improvemeatis sold within one yearolcompleti-ry the owner_ tulderwlllhave
turdenofpmving that he dW net build orlmprovc for
purpose of sale.). J7RM
2ANC:
G PERMIT FEEaeownerthe property,am exclmively contraingwith I]aused FLOOD ZONE APN
conttarutmct theproject(Sec7614,BuemrssandProfeseioaCode: raTheContncuu. lauseLawdnapplytonowner M property whobuilds or tmprwee thereory and who contracts (or each ptojecly wIM aT-WATER I-bq0tT.cmr(s)Bansed pursuant to the Contractor's LlcameLaellI am exempt under Sec B k P C for this reasonT•DEVICE
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
WORKMAN COMPENSATION DECLARATION RECEIPT N
❑I hereby affirm that I have a certiRote of convent to self-Inure,or a FIXTURES PER TRAP OOL TAX Y N
certificate of Worken'Compereation losurance-racomflad copythereT p o!(Sec. RECEIPT`
3800,Lab CJ GAS EA,SYGTEM-1 INCA OUTLETS PARK FEE Y N
Pollry M - RECEB'T N
�Comany GAS EA.SYSTEM-0OVER CertiBed copy Is hereby lumlahed. ' BUILDING DIVISION FEES
❑Certified copy U Ned with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE'1'RAP PAID
COMPENSATION INSURANCE
(Thlasecti-nneed notbemmpleted lithe permit lcforonehundred dollars SEWF-R-SANITARY-STORM EA.200FT. Date Recel t#
(1700)or len.)
Iartify that In the perfurmancamthe work forwhich this permit is issued, WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
I shall not employ any person in any manner so as to become subject to the
O
Workers'Compensation Laws of California.Date WATER SYSTEM/TREATING PAID
Z Applicant
Z O NOTICETO APPLICANT:H,after making this Certificate of Exempt,you NEW RESIDENTIAL PLMB.__SQFr, Date Recei t#
I"` should become subject to the Workers'Compensation provisions of the Labor TOTAL•
w Code,you must forthwith amply with such provisions orchis permit shall be
LU > deemed rev-ked. _ BUILDING •E
0. G CONSTRUCTION LENDING AGENCY � SEISMIC FEE'
I herebyafRrmthat there is a construction lending agency for the perform P/1�� ELECTRIC FEE
Z ance ofthe work lorwhich this permit Is issued(Sec.3097,Cio.C.) --Z: ��
C> O Lenders Nacre PLUMBING FEE `
LL F Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertilythatl have read thin applicetionand atatethattheabovelnformation
lacomed.I agree m complywith all city and aunty ordinances and state laws PERMITISSUANCE FEE$PAID:
} N relating to building construction,end hereby authotlze representatives of thio
Z city to enterupon the above-mentioned property for Impaction purp-sea. ALTERORADDTOMECH.
(We)agree to save,indemnify an d keep harmless the City-f Cupertino Date Receipt#
against liabilities,jutlgnents,arostvand expenses which may In anywayaccrue AIR HANDLING UNIT(To 10,0DO CFM) SUBTOTAL.-
S 'sa '
against I sequence of the granting of this permit.
AIR HANDLING UNIT'(OVER IO,ODOCPM) CONSTRUCTION TAX
lg.....c AppBrant/Contractor Date EXHAUST HOOD M/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupantstoreor handle hazardous HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date Recel [
Health and SafetyCode Section25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOT L-
F1
No
Will the appliantor lute building ocmpant use equipment or devices t VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area AU
Quality Management District? BOILER-COMP(3HPOR 100,0fO BTLn p�
'?h Yes No
averead Healthe h
car ouamade,Ssrequ725505, 5533underaChapter.1 of BOILER-COMP(OVER 100,000 BTU) PA10
the
erstan l.that
building
Coee,Sections25505,ve a tand25534,I /)n�
rcdpontandthat lithe ntify the occupces note rrentlyequir haveat hkh that b is my NEWRESIDFN77ALMEGH. SQ.FT
rgpoto hou nonof afylhe-cats of Ocfthe requirements which must be met .p
prior to Inuanre of a Certificate of Occupancy. /
0,y 01-
p
Owner or authorcmd agent Data
n ISSUED BY: V lJC.ir'1
OFFICE COPY