23171 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification PERMITNO.
Building Address:
23171
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a ame: one.
APPLICAIIUN SUBMI1 IALA
CITY OF CUPERTINO-BUILDING DIVISION
G° °orBNa °' uc."°= APPLICATION /PERMIT C
BUILDING-ELFCTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL N
Arch) ct gineer. Lie.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address
❑ ❑ 1� ❑
LICENSED CONTRACTOR'S DECLARATION PFRMITISSUANCE
hereby
firthat
morder povilonso/ hr9(com
APPLIANCFSRESIDENTIAL
InthSoceon7000ofsl=3oftheBuslmandProfssmsCodeand my JOB DESCRIPTION
uc,raai.l.r-ur° andeffe-.
PANELS rN�
Lkerseclass Lle# 4( y, �� �
nate_/= =aP�_cont'ador y /W
ARCHITECTS ECLA ATION 201-1000AMP5
800 I understand my plans shall be used as public records. OVER1010AMPSSQ.FT.FWR EA b/SQ.FT.
Cd femra
u Licensed Proial SIGNS ELECTRICAL
<N OWNER-BUILDER DECLARATION
t..,�?; I hereby affimnthatI am exempt fromthe Contractors License Law for the SPECIAL CIRCUIT/MLSC
po a following ream.(Section 70413,Businessand PmfmnkmsCude:Myctyor
TSMC METER OR POLE INST.
Kye'� cwntywhlchmqul aPert twmvtrucLaller,lmprovgdemo)bh,ormpalr
anystmc mpdorto Rslsmame,aLwrequr theappbuntf°rsuchper tto 5 POWER DEVICES file a signed statement that hu Is licensed pursuant to the provisions of the
Contractor's License Law Chapter 9(comnendng with Section 7000)of Divi-� SWIMMING I00L ELECTRIC 0� shm3 ofthe Business and PonesslonsCode)orthat he b exempitherefromand VALUATION
yd the basis for the alleged exemption. Any violation of Section 70313 by any
a bcantfora rmitsub ctsthea llcanttoacivil nal f -t momthan OUTLETSSWITCHESFIXTURES
PP a Is PP Pe ty o n
�R five 1,as o nerdolof the pr. NEW RESIDENTIAL ELECTR
jX ❑I,eaownerlltheproperty,d my employeeswithwagesrtheirsole `••O� STOWFS TYPE CONSTRUCTION
C compensation,Boxdo the work,
and Prfmd stru c: is Thna intended oroffered for
sale(Sec 7044,Busbiew and Pr°fessbre Cade:The ContraCota Llarue Law
$ does not apply to an owner of property who builds or improv-thereon,and
who doss such work himself or through hisovenemployees,provided that such OCC.GROUP RES.UNITS
improvements arena intended oroffered fcrsale.If,however,thebuilding or TOTAL:
i provementissoldwlthlnaneyeamfcompletioglhe owner-builderwlll have
t rden ofpmving that he did not build orlmpmes for Purpose ofsale.). QTY PLUMBING PERMIT FEE ETADDMNF. APN
LL as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE 1'UQ
contractors to construct the project(Sec 7044,Business and Professions Code: \-'
The Contractor's License Taw does not apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
bulkis or Impthereon-tractson, and who on-tracts for such piojets cwith a
cga4actor( roves s)Ikensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
Lj I am exempt under Sec. B k P C for this mason
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
S WORKMAN COMPENSATION DECLARATION RECEIPT#
❑1 hereby affirm that I have a nertificate of consent W mWinsure,or a FIXTURES PER TRAP SC IDOL TAX Y N
certificateof Workeri Compemationlmur morardifledcopythere-f(Sec. RECEIPT
3M,Lab C.) GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Pollry N GAS F.A.SYSTEM-OVER 4(EA) BBC=N
G������inpppp zy BUILDING DIV ISION FEES
oLCertified copy is herebyththe d.
Certified ropy u filed with the city
Inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
ity
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(fhissMionneed not becompleted DSEWERSANTIARYthe permit isforom hundred dollars STORM FA.2WFT. _vo Date Remi t#
(8100)rtifyt or .) - WATER HEATER W/VFNT/ELFCTR ENERGY FEE Y_ N_
(certify thatinthe person nmofthework so as to bthis pe mat Is tailed,
i I rk not employ any person In any manner at u m become abject to the
O Workers'Compensahon laws of Gll(ornla. Dnte WATTR SYSTEM/TREATING PAID
Applicant
Z 0 NOTTCETOAPPLICANT:H,ahermakingthb Cc fflr me lExemption,you NEW RESIDENTIAL['LMB._SQ.Fr. Date Remi t#
should become subject to the Workers'Comperualion provision el the Labor
CC N Cade,you most forthwith comply with such powisloru-rthis permit shall he TOTAL:
U > aeenea revoked. B I DING •-E
III.
p CONSTRUCTION LENDING AGENCY SEISMIC FEE
= Z I hembyaffirm that there is a construction lending agency for the perform
once ofthe work forwhich this permit u issued(Sec.3097,CIv.G TOTAL: Q—� ELECTRIC FEE
LL O Lenders Name PLUMBING FEE d CQ
ly F Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icerlfythat... rcaalhtsapp.calbnandaatethatthe above Information
1-correct.I-greet-comply with all etyand county ortlinanmsand state laws PERMIT ISSUANCE FEES PAID:
Y N relating to building construction,and hemby authorlu representatives ofthis
Z city to enter upon the above-mentioned property for inspection purposes. ALMORADDTOMECH.
— (We)agree to save,irMemnity an d keep baroness the City of Cupertino Date Receipt#
gaffisqabBlDes,judgments,matsand expenses which may In any wayamue AIR HANDLING UNIT(TO 10,OW CFM) O
rut Id City inceeseryen of the Smoot.ngnni
ofthispet. SUBTOTAL'
/-:V! AIRHANDLINGUNR(OVERlit"CFM) CONSTRUCTION TAX
bignznm of Applicant/Contractor —D,.e- EXHAUST HOOD(W/DICT) CONSTRUCrION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle havrdous HEATING UNIT ITO 100,000 BTU)
rnaterul as defined by the Cupertino Municipal Code,C hapter 9.12,and the Date RCCCIDI#
I lealth and Safety Code Section 25532(a)I HEATING UMT(OVER 1D0,000 BTU)
❑ Yea .�]N- TOTAL: 38.[9
Will the xpplicant or usaruturebuilditg.,define use tequipment he Bay Area devices
VENTILATION (SINGLE RESIDI JSSUU�C DALE
which eMahagements airrict? nb as defined by the Bay Area Air �'..#1 M
• !N lity Management District? 'OR I KOW BTU(
Ycs t�No
4havc
read the h`ousmteriabrequbementsunderChapter6.95ofCOMP BTU)
the Glifomia Health&S-fety Code,Sectio®25505,25533and2SSM:IJAN Og 1992
understand that if the building does not currently have a tenant,that it is my NEW MECH. SQ.FT.responsibilityto notifythe oavpmofthe requirements which mustbemetprior to issuance ofa Certificate of0ccupancy. CIIY Ut- uur'Ch I11VU
Owner or auth-rtrcd agent Date <
TOTAL: ISSUED BY:
OFFICE COPY