23531 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
B.Ildin Pra'e,t Identification PERMIT NO.
Building Address: 23531
O/'e / `C/� /a7, /711
one: -
-Z 7,f ?CITY OF CUPERTINO-BUILDING DIVISION
Lontractor's Name: Lie.No: APPLICATION I PERMIT
BUILDING-ELECTRICALPLUMBING- FL MCAL CATEGORY CONTROLX
'. „ect/Engineer.
LI,.No:
BUILDING PERMIT INFO'
QTc, ELECTRIC PERMT6•* - � �FEE
ki
Add.: PERMITISSUANCE � o ❑ o
LICENSED CONTRACTOR'S DECLARATION
[hereby alfbmthat lson,Bcenud under provislonso(Chapter9(commen APIaLIANCESRESIDEN7IAL JOB DESCRIPTION
ingwith SeM.n7000).f Divlslon3of[he Businessand Pro(eul.nsCod,and my
l
isense bin fulltorte and effect PANES
Limnse Class LICX
Date Contractor
ARCHITECTS DECLARATION 301-I000AMI5
{OZ Iunderstand my pbmshall be used as public records. OVER IOW AMPS /�iQ�FT. EA 5/SQ.Ff.
O l�J
F Licensed Proleslonalxxx
SIGNS ELECTRICAL _ - -
'z OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC t
s�j m Ihereby affirm l aexempt from the Contractor's Licenae Law for the
following reason.l5ectlon 7m15,Businen and Pro(esslona Code:Mycity or TEMP.METER ORPOLE INST. czz 2
=p county which requires a permit to construct,alter,improve,demolish,or repair
35.'11 anystrudure prior to its issnance,.bu,requires the a ppecant I...uchpermitto POWER DEVICES
2 5 file a signed statement that he is 8mnsed pursuant to the provisiom of the
)c� Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWMMING POOL ELECTRIC VALUATIpy
'05 si..3.fthe Btumessand Prof.ioru Code)mthat he lsesempt therefromand
�.' the basis for the alleged exemption. Any violation of Section 70115 by any OUTLEISSWITCEE�FIXTURES Gi (Din xx
applicant fora permit sub*m the applicant to a civil penalty of out more than
ndmd dollars(5500). NEW RESIDENTIAL ELECTR SQFT. STORIES TYPECONSTRUCTION
as owner of the property,or my employees with wage as their sole
7.� epensation,will do the work and thestructure is ont intended or offered for
C O Ie(Sec 7044 Business and Pretensions Code:The c.mract.e.License Taw
j does not apply to an owner of property who Wilds or improves thersvn,and OCCGROUP RES.KNITS
Who does such work himself.,through his own employed,provided that such
Improvements are not Intended orotfered for sale.It however,the Wilding or TOTAL:
improvement bedd within one year o(campletiaN the owner-bu8derwlli have
the�kurden ofpmving that M did rect build or Improve for purpose ofsale.). CITY. x, PLUMBING FLOOD TONE APN
[�I,as owner of the property,am exclusively mntratling with[leered p9M17 ISSUANCE
contractors to construct the project(Sec.7M4,Business and Finitude.Code:
The Contmenor's Limnue law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER MA)
WBda or Improves thereon, and who contracts for such p(ojem with a .,}A: 1; ;,FEE SUMMARY
cq,lTador(s)uttnsed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE OUTSIDFFFES
• '
L_f I am exempt under Sec B &P C for this reason
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
Avner Date RUCEOT X
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOL TAX Y_ N_
• E:]1 hereby.flim that I have a mrtlBcate of consent to self-marc,ora RECEIPT X
ertlBcate of Worker Comperuatlon WurancaoramrtiFled copy thereof(Sec CAS,EA.SYSTEM-1 WC4 OUTLETS PARK FEE Y_ N_
3800,Lab G) RECEIPT X
Policy N GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
ComCertny
ified copy Is hereby furnished. GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy Is(Tied withh the city dty Impectlon division.
CERTIFICATE OF EXEMPTION FROM WORKERS GRFASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM E.A.2WFT. Date Remi tic
(17bas,etion need not be completed lithe permit is for one hundred dollar
(5100).rless.) WATER EIEATF3T w/vFxfiE.EGTx ENERGYFEE Y_ N_
I eertifythat inthe perfomunce of the work forwldch this pem it is Issued,
I shall not employ any person In any manner m m to become subject to the WAS WSIEMITREATING PAID
Workers Compensationlawsot Callfomia.Date
I Z Applicant NEW RESIDFMIAL PLMB. SQ.FT. Date Remi lb
D NOTICE TO APPLICANT:If,after making this,Certificate of Exemption,you
should become subFct to the Workeri Compenasation provisions of the Labor
5 TOTAL:
Cad,you must comply With provisions or this permit a hall he BUI DING
j dmm d revoked. SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hercbyalfimttlut there is a mrtstmdlon limiting agency for the perform TOTAL: ELECTRIC FEE
Z ance ofthe work for which this permit beocand(5ee 3097,Civ.C.) PLUMBING FEE
) O Lender's Name s
I— Laruers Addrev QTY. MECHANICAL PERMIT' - FEE MECHANICAL FEE
1udifythat l have read thbappikation and statethatthe above ledomution FEES PAID: -
W is mrect.I agree to complywith all dtyand muntycreinancesand state laws PERMIT ISSUANCE
- N relating to building construction,and hereby authorize representatives;ofthis ALTER OR ADD 7D MECH.V) dry to enter upon the above-mentioned property for hapection purposes. Date Recel tH
_ (We)agree to save,indemnify an d keep harmlev the City of Cu pedant,
against habNtles,pdgments,costs and ex per.which may litany way accrue AIR HANT)LING UNTT(TO 10,000 CFM) SUBTOTAL:
against said CiV consequence of thegr ting of IN.permit. CONSTRUCIIONTAX
AIR HANDLING UNIT(OVER)o,WO CFM)
'Gaa� CONSTRUCTION TAX PAID:
g re Applican/Con ract6r Date EXHAUST HOOD(W/DUCT)
HAZARDOUS MATB L SDISCLOSURE HEATING UNIT Will the applicant or future bulldin pant store or handle hazardous Date Recel tic
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the
Health and Safety Code Sadie.35532(x)1 HEATING UNIT(OVER 1 00,000 BM TOTAL
El Yes VEN"IIIATION FAN(SINGLE RFSID) ISSUANCE DATE
W 01 the applicant or rfunu future building occupant use equipnstm or devices
which eMt hazardous air contaminants as defined by the Bay Area Air
Qua lily Management Distinct? BOILER-COMP OHI'OR 100,OW BTU)
?Yes �1 No
have mad the haza2materials requirements under Cha poor 6.95 of BOILER-COMP(OVER IKilts)BTU)• s the California Health Cade,Sections 25505,25533 and 75534.I A f iJ
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT
responsibility to notify the occupant of the mqu imments which must be met /I
P".,to Issuance of a Certificate of Occupancy.
Ownc,o,authmizud agent Date TOTAL. tSS e,Blv L
OFFICE COPY