23672 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification - PERMIT NO23672
Butting Address:
Pt L" ist
ams:
suns s 3 6 CITY OF CUPERTINO-BUILDING DIVISION
t ctor'sName: 1 Lc.No: APPLICATION / PERMIT (J ' L�
715 CATEGORY CONTROL#
rchlteet/Engiraer. Lie No: BUILDINGELECTRICALPLlJM01NG-MECHAMGL
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. PERMITISSUANCE ❑ 1:1 ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm elutions licensed under provisions o(Chapter9(mmmmc APPLIANCES-RESIDENTIAL JOB DESCRI'1TON
ingwith Secthm700D).f Dlvlelon3 ofthe Busisse and ProfenlonsCode,and my V� e
Ii=lain full me. deffet. PANELS
Licen Cam Icp ��- _� We 1
DateContnator +' -
ARCHITECTS
DECLARATION 101-10DOA.MPS
O I understand my plans shall be used as public records, OVER I ODD AMPS SQ.FT.FLOOR AREA $/SQ.FT.
E Licensed Professional SIGNSELECTRIGL
G�6 OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISE L1 G
ZL, IherebyafOrmthat Tam exempt from the Contractor's Licenm Law for the I I�1
following reason.(Section 7071.5,Business and Professions Code:My city or
� I"' coon hick bna rmitrommtru atter,lm mve,demolk p TEMP.METER OR POLE INST. j a� a..�
vJ ' tm re9u Pe d. P h.erm air P �. J IB�� BSB`
IT...i ex, price tatemeiteht Issuance,aW requlmsuanttthe the cant proch visions
of
te ppWFR DEVICES
file a signed statement that he k r licensed pursuant it the tion 70ons of the
co' gas, 041
E, Con3ofth sLlceme Law(Chips.mCod)orthathebe mptthemfmmlvl-
3 O G SWIMMING POOL ELECTRIC
ebn3oRhe Buelnemand ProfembmCode)orehat hebexemplhere(romarM r0CC.GROUP
yd S the basis for the alleged exemption. Any violation of Stolon 7031.5 by any -
aO5
applicant for a permit subjects the applicant to a civil penalty of one morethan OUTLETSSWITCFIFSF[XTURFS five 1,asoner of the pr). NEW REWENHAL ELFiCTR SQ.FI'. TYPE CONSTRUCTION
❑Las owner of the property,or my employers with wages r their sokcompensation,will B..b, the workandthes Code:Thi not Intended or offered fordoe(Sec. pply to as owns d f prupe.ns ho b:The Coeseves Llano Lawdonnt apply Bork owner orpropertywhobuildsorImprovethercoryandRES UNITS
whodoe neeh are net cote dedorwghed owns.If,hoea,p ovided,theb th t suchleftort
improvementsarenotintended earofc !.reale.ILh er-q gofer l lI have TOTAL:
Improvementbsuidwithln oneyearolcompleliogtheowner-buBderwlllhave
BILIJurden of provingthat he didem buBd or improve forpurpose ofeak.). QTY. PLUMBING PERMIT FEE FLOCOZONE APN
11 4 as owner of the property,am exclusively contracting with licensed
contractors to construct the project(Sec 7W4,Business and Professions Code: PERMIT NUANCE ,Uo
The Contract.?.License Iew don out apply to an owner of property who
builds or Improve themon,and who contracts for such pkejeM with a ALTER-DRAW 4 VENT-WATER�U
co�ateta(s)Ilcenmd.pursuant to the Cmiactoe.License Law. FEE SUMMARY
I am exempt under Sec B k P C for this rcnon BACKFLOW PROTECT.DEVICE
OUTSI DE FEES
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
Owner Date BBC=if
^/ WORKMAN COMPENSATION DECLARATION FIXTURE,PER TRAP SCHOOL TAX Y_ N_
Def hereby affirm at I have a mrtlBnte of consent to mB-insure,or a
m Tecate of Workers'Compensation Laurance ma mrtiBed copy thereof(S.C. RECEM
3800,IebCD �9 PT
GAS EA.SYSTEM-1 WCAOUTLETS PARK FEE Y N_
PolityR 0. f �_ DING DIB
Ci GAS EA.SYSTEM-0VER 6(EA)
Com anv A� j� BUILDING DIVISION FEES
[rCertNed copy here th the city
d. GRFASE/INDUSIRLWASIEWTERCEPTOR PLANCHECK FEE
mpybllkd with the city lnspectl.n division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
-
COMPENSATION COMPENSATIOINSURANCE SEWER.SANITARY-MRM FA 2XFT Date Receipt#
(Thlaeectlon need not be completed the permit 4lorene hundred tartars
0100),Icax) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
permitbl
I enifythat la the performance of thework forwhich this permit is ued,
I shall not employ any person In any manner m as to become eubje t ee the WATER SYSTEM/•IREA•INCA
Workers Compensation Laws of California.Date PAID
Pp NEW RESIDENTIAL PLMB.
Applicant ��,,
Z O
NOTICE TO APPLICANT.If,seer rs'Co pecution his ateofons of
the you
Date Recti t#
(- should become.ubjd to the Workere'Compensatlen provklons of the Lebon. TOTAL:
N Code,you must forthwith comply withsuch provisoes or this permit shall be BUILDING
FEE
W j deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
tl I hereby af(Irmthat there%a construction lending agency for the perform- 1 ELECTRIC FEE
7 arm of the work for which this permit b Wued(Sec.3097,Civ.C.) TOTAL:
0
() Lereder.Name - 21-a PLUMBING FEE
IL F Lender'.Address QTY.I MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icenifythatl have read this appliationand gate that the above Information
V cored.I agree to comply with all city and county ordleanceaend nate law. PERMITISSUANCE FEES PAID:
} N relatleg m inllding construction,and herebyauth.nm expesecoutwes.f this
(— citytoenterupon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
? (We)agree to eve,indemnify an d keep harmless the City of Cupertino Date Receipt#
V
against liabilities,jadgerems,mKs and expenses which may In anyway atoue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL' s'
.g.fDaj said City lnmnse en. of she granting of this permit -
p AIR HANDLING UNIT(OVER IO,ODOCFM) CONSTRUCITION TAX
Sig tureof AppOa nra or d Date EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
H 'i"' ad DISCLOSURE
Wllltheapplian orfumre building.ccupant Store or handle hazardous HF-ATINGUMT(T0IDg000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.11,and the _ Date Recei t#
Health and Safety Code Section 7553107 HEATING UNIT(OVER 100,OOD BTN TOTAL:
F-1YenNo
Will theapplimntorfuture building occupant use equipment ordevics, VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which sent hazardous air cenUmdra n s as deBmd by ten Bay Area Air p
Quality Management District? BOILER-COMPOHPOR 100,000 BTN PA I D
I—I Y:sf-1 Na
ave read the Fcnia aza ous materials rcqulremenb under Chapter 6.95 of BOILE2COMP(OVER 100,000 BTU)' AUG1 Q (�
understand that lithe buildinHealth& g does not currently atenan3 and l5hat itlL my NEW RESIDENTIALMECH. SQW. A8 1992
mepmaibilityto ntifythoompant.f the requlrcment.which at be met a
prior to istuame of a CetlBceteot Occupancy.
TTY Ur wrtnulvu
Owner or authorized agent Date ISSUEDBY:_ t
70TAL:
OFFICE COPY