23377 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification =PERhRT NO.
Build I.,woos _ '0., P 23377
e anter _ - A .
03,S__(::> CITY OF CUPERTINO-BUILDING DIVISION
c r'rt ''Ne.: LIc.No: APPLICATION / PERMIT h6 _
BU[LDING-ELPCnUCALPLUMBINEC
G-MHANICAL" CATEGORY CONTROL
AMhltectgineee. Llc.No:
- QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO ,
Address: BLU� ELU�l PLUMB MI"'
PERMIT ISSUANCE [_] ' ❑ �P ❑ .
LICENSED CONTRACTOR'S DECLARATION _ LAY
I herebyaffirmlhal lam licensed materprovisionsof Chapar9(marmen APPLIANCES-RESIDENTIAL JOB DESCRIPTION
2with Secdon70M)of Dlvig.3 ofthe BusNessand PmfesslonsCode,and -
nse Is in ran force and effect.
PANELS
License _ LX S 7S
DateV.2SContractor - —UP TO 2DO ANUS
�.�•/� �/'.JM+s
ARCHITECPS DECLARATION 201-1000 AMPS `
raQCO lundentandmyplamshaUbeus mpubhcmewds. OVER1000AMPS SQ.FT.FLOOR AREA ,$/SQ.FT.
Limnsed Profs®Wesal SIGNS ELECTRICAL ® O
<'a- 'OWNERBUILDER DECLARATION SPECIALCIRCUIT/MISC l
owing ak s.(Secs on 7MI exempt Goat the Contractor's License law for the
oo following reason.(Section 71T115,Business and Pro(essbns Code:An city or
02 y ty - TEMP.MITERORPOLEINBT.
p4 countywMre requlresapemdtro alsoreuircatheaplicamfr such,orrepalr
any structure pdemenIts hat hela;suance,ahoregpursuant to the rovistoss ofNte POWER DEVICES ,,,rrr
O {
file a signed dor's statement that he(Chapter licensed pursuant to the proWlom a( the y /2
3 � Mon 3 ofthe usinseLew andProession(md.)ortng with xSection
mpttherefof Divi- SWAAIING POOL ELECTRIC ` ATE / ON
� d the basis fotheallegedPrcmtion.Any
yvirlationhat f exempt therefrom and
•]]
thebasisfortheallegedjeds the n.
Anyt tolatbn ofSectiono not mbyany OUTLETSSWITCHFSFf%T'URES
m
applicant toacivil penalty al not mnrethan -�
flue hundred dollars($Sfp). NEWRESIDENnALELECTR SQ.FT. 'STONES TYPE CONSTRUCTION
�n
-❑I,as owner of the property,or my employees with wages as their sole
comForeman,wBldothe work,andthe structure is not intended or offered for
O rale(Sec.7096,Business and Professiona Code:The Contractors License Law
�2 does not apply to an owner of property who builds or improves thereoMand :GCC.GROUP RFS.UMTS
who doeeauch work himself orlhrough his own employees,provided that such ,
Improvements are not intended oroffered for sale.If,however,the building or TOTAL:
improvement is sold within oneyearofcwnplelion,the owner-bu0derwill have
tlgr}avden of proving that he did not bund or improve for purpose of soled. QTY. PLUMBING PERMIT FEE FLooDwNE APN
L j I,as owner of the property,am exclusively contracting with]Icensed PERMIT ISSUANCE
contractors to construct the project(Sec 7094,Business and Professions Code:
The Contractors License law does not apply to an owner of properly who ALTER-DRAIN&VENTWATER(FA)
.bunds orEmpves rathereon,and who contracts for such pra)ecte - -with a FEE SUMMARY
-,. ylfto licensed pursuant the Contractors License Law. BACK FLOW PROTECT.DEVICE
LII am exempt under Sec. B k P C for this reason
i Owner Date DRAINS-FLOOR'ROOF,AREA,COND. SANITARY Y_ N_ -
WORKMANCOMPENSATIONDECLARATION RECENTp
'�1 by
ef(Irm that I haves certi0raro of consent
to self-Insure ora FIXTURES PER TRAP SCHOOL TA% Y N_
I to of Wmkere CompenaaBonirourance ora candf4d copy thereof(Sec. - RECEIVE -
3800,GbC GAS F.A.SYSTEM-1 INCA OUTLETS PARK FEE . Y_ N_
PDI.Yy[L'�[ DINGRECEIVE X
- y e _ _L LaW' 7 �r GAS EA,SYSTEM-OVER4(EA) ..
Cam an - - ,BUILDING DIVISION FEES -
Certlfi d copyEs ereby mislaid LA
CREASE/INDUSTRL WASTE INTERCEPTOR
PNCHECK FEE
Allied copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID I -
COMPENSATION INSURANCE SEWF-R-SANITARY-STORM FA 20OFT Date , Recei t#
(1'hiasection need not becompletespermit hundred dollen
($lW)orlessJ. WATFRHE/TERW/VENT/66WiRr ENERGY FEE Y 'N
performance certify that In the perfounce of thework forwhlch this permit is issued, ;5
I shall not employ any person in any manner an,as to became,subject to the WATER SYSTEM/TREATING "
Workers'Compenartion Laws of California.Date PAID
O Z Applicant NEWRFSTDENTIALPLMB. SQFf. Date ' 'Recei t#
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should become subject to the Worken'Compemation provisions of the Labor - TOTAL:
Cy Code,you moat forthwith comply with such provisure,or this permit shall be MG FEE,
W > deemed revoked. „
CL t] CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there b a construction lending agency forthe perform ELECTRIC FEE
3 Z ance of the work for which this permit is issued(Sec.3097,Cu.C.) TOTAL:
U O Tender.Name PLUMBING FEE
LLI— Lender's Address QTY, MECHANICAL PERMIT FEE MECHANICAL FEE
OW IcerU/ythatl havereadthisapplicationand elate that the above information
1 iscorrecl.I agreeto comply with all city and county ordinancesandstate laws PERMIT ISSUANCE FEES PAID: �� s -
} misting to building construction,and hereby authorlu representatives of this
F Z city to enter upon the above-mamlWned property for InspectionFRFC
Inspection purposes. ALTORADDTOMH. . Da Reeef [#
_ (We)agree to saw,indemnify an d keep harmless the City of Cu pardon P
against liabilltiee,judgments,costs and expenses which may In anywayacnue AIR HANDLING UNITcro 10,000 CFM) SUBTOTAL: •
against said City In consequence of the granting of this permit. AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HFAHNGUNIT(TO 100,000 BTI)) Date ReCe) t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
HcMthand Safely Code dion2S532(a)7 - HEATING UNIT(OVER 100,000 BTU) TOTAL: 7.X Y-4
❑Yea ��SIeNo
Will lheappllcanl odlu[ure building occupant use equipment or devious VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
(wh�hiiclh emit hazardous air contaminants as defined by the Bay Area Air -
ity
t Diadct?
I havetread the haza�ounomaterlals p �aER-COMP OHP OR i00,IXq BTU) pp �pp
r P9 D
requirements under Cha ler 6.95 of BOILER-COMP(O_VER 100,000 BTU)
the Califunderstand
Health building
Code, of currently have
a t and 25534.I
understand that ltlhebulldingdoes not cumenny have atenanq that it is my NEW RESIDENTIAL METH. SQ.FT EjjflD �La �(]�X�
r sponsibility to notify the occupant of the requirements which mu at be not MAR V s7 G
r rtolssuaneeofa III teof Occupancy.
-1S CI Y Ur L nurvv
mer or au o ud agent Date ISSUED B a
TOTAL:
OFFICE COPY