23434 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMT NO.
Building Add.:
23434
wn one: APPLICA HON SUBMI 1-1 AL DA Lk
Ala CITY OF CUPERTINO-BUILDING DIVISION
c°" a neje am: ue.Nm APPLICATION / PERMIT
BUILDING.ELECTRICAL-PLUMBINGMECH MCAL CATEGORY CONTROL M
Architect/Engineer: Lic.No:
CITY ELECTRIC•PERMIT FEE BUILDING PERMITINFO
Address:a - PERMITISSUANCE. ❑ ❑ a - I�I'
LICENSED CONTRACTOR'S DECLARATION - yQ
I hereby affirm that l am licensed under prwLUoneef Chapt.0(cso.c, APPUANCES.RFSTDENTIAL J08 DESCRIPTIONingwith Section7000).f Divi.1.3 ofthe Bueinessand ProfesslonaCpde,and rrry
Li.. isinfell to=and effect PANELS ���'•�11/ +'+
License Chea Um - a'1
Date Contractor
ARCHITECT'S DECLARATION 211-1000 AMPS .
p�v9z I understand my plan shall be used m public records. OVERIOOOAMPS -r SQ.FT:FLOOR AREA $/SQ.FT.
k Licensed Professional SIGNSELECTRICAL
<«<< OWNER-BUILDER DECLARATION
C+ � SPECIAL CIRCUIT/MLSC
z0 owing rafRrmtlutlam31.5,B fromthe d PrAfessio License Taw for[he -
O Appppp followingreasmqu('lection 7031.5,BusinessandProfessionsemle hnycity or
mpair
� I"� countywhkh rcqubcaa penNtto corvwct,alteq Improve,demaWh,orrepatr TLMP.METfROR POLE INST. 1
anyetmdumpdortoits wane, qppp
alsomuimslhealianlforsuchermltto
4
F Ole a signed statement That he Is licensed pursuant to the provisionsof the POWER DEVICES
Owt� Contractor'sLicense Law(Chapter 9(cormencirg with Section 7000)of Dlvl-
ti�OJ elon3ofthe BuelnessandPa.iors Cade)orehathebexemptlhemfmmand SWIMMING POOL ELECTRIC VALUATION_ -
< the bash for the alleged exemption. Any violation o(Sectlon 70315 by any OUILETS-SWITCHESFIXTURES
applicant fora permit subjects the applicant to a civil penalty ofnet more than
five hundred demodollarthe pr), NEW RESIDFMIALELFGTR_SQ.FT. STORIES - TYPECONSTRUCHON'
(tin
1,as owner of the property,or he employees with wages r their sole
�7P .1.(Sec.
will do the work,and IhesC dere h not Intended or offered for
F p ale(Sec.apply
to as essow er f property
who
buildsThe Con[ra.the. Law
$� does notostutch torn owner o(p rough isownedaoym,pr esthereoryand OCC.GROUP RFS.UNITS
e•
who doementsa not mself or Intended through ownemIf,how,ez,theedthat goo
Improvementsarcnm Intended orr.fc !creak.theonvegthebutldingoe TOTAL:
improverrcntbwld within oneyearo(completbrytheawner-6u8derwEl have _
tflLtsurdenofpmvingthat he did not build or improve for purpose ofsak.). QTY. PLUMBING PERMIT FEE FLOODZANE APN
u I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Pr fesslors Code:
The Contmemes Lkense Law does not apply to an owner of property who
bu8ds or Improver thereon, and'wha cantrsda for such p(ojects with a ALM-DRAIN&VENT-WATER(EA) -
c96¢actor(s)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
ec
LI I am exempt under SB &P C for this reasonOUTS I DE FITS
Owner Date DRAINS FLOOR ROOF,AREA,GOND, SANITARY Y N_
RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAX Y N
QI hereby ork that I have o Insurance
ate of consent to spytheure,or RECEIPT X
3800,Ub of Workcri Compensation Insurance ora anl(led ropythereof(Sec. '
' 3800,tab CJ GAB-EA.SYSTEM-1 INC.40UTLLTS PARK FFE Y_ N_
Policy p GAS G.SYSTQM-0VER d(FA) RECEPi
Cany _ BU I L DING D IVISI ON FE ES
omMCenifled copy Is herebth the
CREASEANDUSIRL WASTE INTERCEPTOR PLANCI-IECK FEE
MCertlOed ropy h w
filed with the dly Inspection division. -
CERTIFICATE OF 1W, EPTION FROM WORKERS' GREASE TRAP PAID.
COMPENSATION INSURANCE - - SEWERSAMTARYSTORM EA 20017 .Date ' ROtel t#
([firvi ion need not be complded I(the permit hfar one hundred dollars
($too)nilyth WATERT EAITERW/VENT/ELECTR ENERCYFEE Y N
I cent that In employ
anpersoniperformance any
he coo ok fors to become
is apermit ubj is Issued, —
I shrE not employ any person In any manner n as to become abject to the WATER SYSTEM/TREATING
Worke 'Comwnpensation Laof California. Date PAID
O. n
Z NOTICE NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
Z O NOTICE TO APPLICANT:I(,akar making[hh Cenlflala o(Fxemptlon,you
should become subject to the W°rken'Compmsatlon provblou of the Labor - TOTAL:
V) Code,you most forthwith comply with such provision orthls permit shall be BUILDING PEE
LU ] dermedrevoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Ihembyaf@mthatthem h a construction lendingagcory f°rthe perform- ELECTRIC FEE
Z -ance ofthe work forwhichthb permit is lssued(Sec,3097,Civ.C.) TOTAL:
00 LendersName PLUMBING FEE
LL I— Lendce.Address QTY. MECHANICAL PERMIT FEE MECIiANICAL FEE .
OW lani(ythatl have readthts appllestl°nand katethatthcabovelnformatlon
a, Is correct.Iagreetocomplywith all eityand countyomanancesand statelawe PERMITISSUANCE '�' FEES PAID:
} relating to building construction,and hereby authorize representatives ofthle "
(. Z city to enter upon the above-mentioned property far lmpection purpose. ALTER ORADDTO MECH. Dale ReCe) t#
V _ (We)ages to rave,Indemnify an d keep harmless the City°f Cupertino
ago lest lhb(lltka,iadgn¢nis,mYs a Ad expenses which may In any way amue AIR HANDLI NG UNIT(TO 10,000 CFM) SUBTOTAL:
Signeagaire bCltyl me nm of she gaming oflhb permit qIR HANDLING UNIT(OVER 10,000CIM) CONSTRUCTION TAX
/ ont or Date O(FIAl15T HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA2ARD S ATERIALS DISCLOSURE
Wiiltheappllant or future I fl ecapantstoreorhandle,hazardous HEATING UNIT(TO 100,0(IO BTU) �' Date ReCei t#
material as defined by the Cupertl no Mu melpal Code,Chapter 9.12,and the
I1e❑alt Yaannd Safety CodeLSecttoon 25532(a)7 HEATING UNIT(OVER 100,000 BIT P TOTAL:
Will the a pplla est or future building occupant use equ 1pment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
-which emit hazardous air contaminants as defined by the Bay Area Air
• Quality Management District? BOILER-COMP QHP OR 100,000 BTU)
I Yes g No R1 p I qct
haverlheth& outy Code breuns 255ntsunderChap53.1 of BOILIiR-COMP(OVfIt 100,0(10 BTU) H� P9 Y
the Californiaand t at tithe
&Safety Cods Sedlom 25505,have
a t and 25534.I
understand that lithe building does not currently havcatenanl that ltbmy NEW RESIDENTIAL MECH. SQ.1717. !NAR 23
responsibllilyto nutlfythe onvpart ofthe requUementawhich most be and 1992 /)
prior to Issuance of a Certificate of Occupancy. Ix7x7L 14f(`O�'/',
CIIYI . a,
Owner or authorized agent Date ,roT !• �s W13411
ISSUEDBY:_
OFFICE COPY