23356 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Pro ed Identification - - PERMIT NO.
Building Asg Kliwin Ln - 23356
ann: / ane:
�Fj21T{ L—z_eck- CITY OF CUPERTINO-BUILDING DIVISION
co^ 7 Name: Lie.No: APPLICATION /PERMIT I ` t�Caar�-� BOLDING-TIBCTRICAL-PLUMBING-MECHANICAL CATEGORY CONTROL#
Architect/Engineer / Lk.N. .
c QIY ELECTRIC PERMIT FEE BUILDING PERMIT INFO-,
Address:/ ISE . I'ERhBTI55UANCE i.'
L !�[J El El ❑
' - LICC ENSED CONTRAONTRA CTOR'S DECLARATION L.�J
I hereby affirm that l am licensed under provisions of Chapter 9(communc APPLIANCES-RESIDENTIAL JOB DESCRfPTTON
Ingwlth Section 7IX0)of Dlvlsloo3ofthellualuessand ProfesslonsCede,and my
IirenselelnfuBforreandeffect. PANELS .
License Class Lle# 3'6 /S'7/ (a "'h%_e,
—e,
Date - Contractor
ARCHITECTS DECLARATION 201-1000 AMPS
0m20 I understand my plana shall be used as public records. OVER IODO AMPS SQ.FF.FLOOR AREA S/SQ.FT.
Fi Licensed Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION
.SPECIALCIRCUIT/MLSC
GGG lhercby affirm lhallace exempt from the Contractor'.License Law for the
o following ornte.(Section 70315,Business and Prefenions Code:Any city or
0 21-• TEMP.METER OR POLE INST. -
P� county which requires permittoronatroct,alter,lmprove,demolish,orrepair ,
$m nystm=mprlortoltalawancgaL+ requlrcstheappticantfo mchper tto POWER DEVICES
15 r4
file a signed statement that'ha b licensed punuanl to the pmvlame,of the -
3w 9(
t
Contractors License Law(ChapercommencingwlthSedlonAXt))ofDlvl-
O In SWIMMING POOL ELECTRIC
the Wsi the the alleged Profembn. Any nutation f scampi theraf7WIS by and 1 VALUATEO
16pS51 •.t the baani for the alleged exemption.applicant
Any violation o!Secpenalty
o 7m L5 by any OUILETSSWITCHPSFIXHJRFS D
6�
applicant for aperrs L$50 Mathcapplkanttoadvil penalty of not name than �J
Ov I,as owner dollars pQ. - NEW RESIDENTIAL ELFLIR SQFf, STOUTS TYPE CONSTRUCTION
�n meas owner of the property,or ho employees with wages r Ther dole
ed for
C .1.(Se.7044,will B.Mire tM1ewarkand
ssions rudurcis he Contactor ormouseLw
5a Q dole(Sec. ppy to alnowandf property
Code:TheCImproves theme,and does oeee apply torn owner orthmagywhoWilds nemporlmprwvided that
and ., OCC.GROUP RFS.UNITS
c0.. whodceesuchwork himself orthrough his ownemployeea,provided that such _ ,
Improvements are not intended proffered forule.If,however,thebullding or TOTAL:
Improver ntbsold Withinoneyearofcompleion,theowner-bullderwlll have
tlajZurdenof provingthathedid notbuildorimpreve lorpurpowofule.). QTY. PLUMBING P MIT FEE
u FLOOD ZINE APN
I,er owner tr the property, Se exclusively Business
contracting with Sensed PERMIT ISSUANCE
The Co on to construct the project(Sec.7094 to an o and Professors property
Code; a
.The Contractor's Impr e License law does net apply to, f owner p properly who ALTER-DRAIN&VENT-WATER
o Ills t r Imprensa[person,and who rontrada for each ptojecte with a
c�pLfader(eexem licensed
underpursuant mthe Contractors License Law, BACK FLOW PROTECT.DE FEE SUMMARY
L,JI am exempt under Sec B&P C for this reason
Owner r DRAINS FLOOR ROOF,ARRA, SANITARY Y N
.� Date RECEIPT p
WORKMAN I have
DECLARATION FIXTURES PER TRAP SCHOOL TAX Y_ N—
❑1 hereby affirmorkem that I have a mrtEcate of consent to copy
or ��,#
rnrtitmbte o(Worker Compenaatlonlruuranrn orarnrtllled copy thereof(Sec, GAS EA.SYSTEM-I INCA OUTLETS PARK FEE Y N
Poll Lab CJ - -
Poll p RECEDING PT DIVISION
. Co CAS EA.SYSITM-OVERa(EA)
a Y BUILDING DIVISIONI'I:IiS
Hated copy b hercbyththehed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CertEed copy b(fled with the city inapectlondivision.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP ' PAID
CAMPENSATION INSURANCE SEWER-SANITARY S[ORMEA200F1'. DRIC Recei t#
(Talc section need'not be completed if the permit b fororu hundred dollars P
(S110)o
I¢rtifyily that In the performance o(thework for which WWATER HEATER W/VENT/ELECTR ENERGY FEE Ysportnit is issued, N_
I shall not employ any person in my runner so n to become subjectto the WATER SYSTEM/TREATING ,
Worker Compenution Laws of Cailfornb
ZZ Applicant NEW LEERED IiAL PLMB. SQ,FT. Date Recei tN
O NOTICETO APPLICANT.H fter making thisCertlficateof Exemp0lon,you
Fshould become subletm
le the Workers'Compeatkae provisions of the Labor TOTAL:
c N Code,you rrwat forthwith comply with such provlslona mthb permltahall be _ BUILDING ••E -
deemed revoked.
.aCONSTRUCTION LENDING AGENCY SEISMIC FEEI hereby affirm that there Is a contraction lending agency for the perfomv GLGCTRIC FEE
Z anceof thework lorwhichthb permit is Issued(Sec 3097,CIv.C.) TOTAL:
U O Lenders Name PLUMBING FEE
<L I— Lender.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I cedllythat l haveread thbapplication and statethat the aboveinformation -
1 brorrect.I agreeto comply with all cityand county ordinances and state laws PERMITLSSUANCE . 'FEES PAID:
N relating to building construction,and hereby authorlve representatives of this
F Z city to enter upon the above-mentlorud property for Inspection purposes. ALTE9ORADDTOMECH. Date Recel SIN
,(We)agree to wive,Indemnify an d keep harmless the City of Cupertino P
against liabilities,jrdgmonta,rostaana expenses which may in any ways¢rue 'AIR HANDLE NG UNIT(TO IDp00 CFM) SUBTOTAL:
agalnstu ty In consequence of th ngofthlepermlt.
_q ATR HANDLING UNIT(OVER 10,000CF'M) CONSTRUCPIONTAX
–ElExaniine of Applicant/Contra Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZA R DOLS MATER IALS DISCLOSUR E
Willlheappllcant orhimm building occupant store or handle hazardous HEATING UNIT ]00,000 BTU) Date RCCei IN
materbI as defined by the Cupertino MuNdpaI Code,Chapter 9.1 2,and the
Iiulth and Safety Cgae Section 25532(a)7 HEATING UNIT(OVER 100,0X0 BTU) TOT
❑Yes No - ...
Will the applicant er tun building occupant use equipment or devices VEMOUTION FAN(SINGLE RISID) ISSUANCE DATE
which emit hazardous air contamleants as defined by the Bay Area Air
Quality Management District? BOME4COMP 0HPOR 100,000 BTU)
'?h Y.d P A I D
alfumLa teeth&Safet mode,Sereons25Sentaun3aChapter,1 of BOR.GR-COMP(OVQt 11)0,000 BLU)
the Gltand thealth building
Code, otcume25505,vntly e a tenant
understand that If the notify
the occupant note'requires,ets which
that it met NEW RESIDENTIAL MUCH, SQ.Ff 41AR - �
mor to
responsibility Heti!ythe cafe of olthenqulrerrenta which must be met 1x1!'1 'lll(�2
prior to Issuance of CertlRcate o(O anry. Is7s7
Cllfllt
r au(hodud agent Date TOTAL: ISSUED BY:
OFFICE COPY