23468 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: _ 23468
5 CCI
netsAPPLICA ILON SUBMI I JALp
Pr CITY OF CUPERTINO-BUILDING DIVISIONA
G^^tact. eName: Lie.N.: APPLICATION it PERMIT L
BUILDINGELECTRICAL-PLUMBING-MECHAMCAL CATEGORYCONTROL.N
Architect/Engineer. Lie.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add. PERMITISSUANCE ❑ ❑ NA ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby ton7DOO)ofDiA I am onsoftheunder Buprovlslonsof Chapter9(mmmm APPLIANCES-RESIDENTIAL JOB DESCRIPTION
It...1 Section f.me.!ieffeon3o(the Buslnessand ProfnslonsCode,and my X..� ,.S�s
license Is in full force and effect. PANELS CV" 1V 5
Date
License Class LION
Date Contractor UP TO 200AMPS
ARCHITECTS DECLARATION 201-10DOA.MPS
p'!.
Licensed PrM
[understand my p6re shall be uxdespublic reowds. OVER]ODD AMPS a �00� 4/SQ.Ff.
COC SIGNS ELECTRICAL J ,/''„
U esslonal _
Qce OWNER-BUILDER DECLARATION p�'�
In• Fn SPECIALCIRCUIT/MIST I 1 p�'''.er(
{. 7 I M1embyafOrm flat i am exempt from the Com due.License Law for the a
7. 11
0,.,'� following reason.(Sedion 7031.5,Business and Professions Code:Any city m, �N ll
F@ county which requires a permit to construct,alter,impmve,demolish,or repair T'�P'MEI'E7(ORI'OLE[NSI'. E / /��
.. any structure prior to its Issuance,also requires the applicant for wch permit to pOkypR DEVICES ` (�
4.i file a signed statement that he Is licensed pursuant to the provisions of the
F COQ ean3.fthesBuicense L,aw sinessand Profeaiom Code)orAer 9 Bheilsumipt thon erefrofi and SWIMMING POOL ELECTRIC VALUATION
•] the basis for the alleged exemption. Any violation of Section 7031.5 by any
OUTLEISSWITCHESFI%TNZFS
EW apperantfor a permitsubjedathe applicant toadvll penalty of not morethan
ve ndred dollars($S00). NEWRESIDENDALELECTR SQ.LF. STORIES TYPE CONSTRUCTION
as owner of the property,or my employees with wages as their sole7a mpenvtlon,will do the work,and the structure is not intended or offered for
❑
sale(See.7044.Business and Professions Code:The Contractors License Law
$$ docs nm applyman owner.fproperty who bulldsorimproveathereon,and OCC.GROUP RES.UNITS
who doessuch work himselforthrough his own employees,provided that such
improvements are not intended or offered for sale.If,however,the building or TOTAL:
improvement is sold within one yearofcmnpldbn,the owner-builderwill have
tli,jiirdenof prxvmg that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
Lj L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
centndon to construct the project(Sec 7044,Business and Professions Code:
The Contractor's License law does not apply to an owner of property who ALM-DRAIN&VENT-WATER(G)
builds or improves thereon,and who contracts for such p(ojects with a FEE SUMMARY
c,J[LLtT ct (a)licensed pursuant to the Contractors License Law. BACK FLOW PROT[CT.DEVICE
LJ 1 am exempt under Sec. B&P C for this reason
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N
. Owner Date ftECEE'f N
WORKMAN COMPENSATION DECLARATION �PER.1.�P �.. SCHOOL TAX Y_ N_
❑I M1ereby affirm that 1 have a certiBate of consent to sell-insure,ora RECEIPT N
cedifialeofWorkers'CompematIonlreuranmoramdifkdcopythereof(Sec. CAS EA.5YSTEM-1 INCA OUTLETS PARKFEE Y N
3800,Lab C.)
:7
RECER f N
Polity X GAS LA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
Com any _
Miffed copy 6 hereby furn+ahed. CREASE/INOUML WASTE IN'T'ERCEPTOR PLANCHECK IEE
Certified copy 6 filed with the city Inspection division.
CERTIFICATE OF EXEM PFION FROM WOR K ER S' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Recei tilt
(ThissMlon need not be complded If the permit 6 forone hundred dollars
(4100)urless.) wATF rLTc w/unser/FI.EcrR ENERGY FEE Y_ N_
I certify that ot the performance of the work forwMch this permit is 6wN,
1 shall not employ any person In any manner so u to become abject to the ' `ATFI4 SYSTEM EATING
Workcrs'CompemaHon laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQFT.
Z O Date Revel tq
NOTICE TO APPLICANT: making this Certificate of Exemption,you
HN should become sub)cet to the Worken'Comperuatlon provisions of the Labor TOTAL:
� ;
Code,you=at forthwith comply with such provisions or this permit shall be B LDING ••G
deemed revoked.
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE
ill C I herebyaffirmthzt there 6 a construction lendingagenry forthe perform T �s ELECTRIC FEE
7 Z anu of the work which this permit is issued(Sec.3097,Cro.C.) PLUMBING PEG
(„) O lenders Name
1L I— Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U Icertifythatl havereadth6 applicatimund statethattheaboee Information
O W is romct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. M relating to building construction,and hereby authorize representatives of this
F Z city to enter upon the above,mentioned property for inspection pu rposes. ALMORADDIOMECII.
(We)a to save,Indemnify an d keep harmless the City of Cupertino Date Receiptk
V agafnat a Illtlm ta,consand swhich may In anyway accrue AIR HANDLING IJMT(TO IO,WO CFM) SUBTOTAL:
agaimt aa+a n acts th< anu spermlt CONSTRUCTION TAX
l _ � •��Q � MR HANDUNc uNrf(OVER lgeeBcpM)
Sig nature of Appllant/Contractor K0/fie EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant cefutum building occupant store or handle hazardous BEATING UNIT(TO 100,W0 BTU) Date Reeei tN
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Ile.lth and Safety Code Section 25537(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL.
❑Yes r]No
Wlllthe applicant orfutumbuilding occupant use equipment ordevices VFd'DLATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defimd by the Bay Arca Air
Quality Management District? BOILFR.COMP(3HPOR 100.000 BTU) P
4Y's I�I No '410
luvercadtheF r�ousmate abrequirementsundcrChaper6.95of BO ER-COMP(OVERIOJ,000 BTU)
the California Health&Safety Code,Sections 7550.9,25533 and 75534.1
understand that if the building does not currently have a tenant,that It 6 m NEW RESIDENTIAL MECH. �R SQ.LT. /TO
responsibility to notify the occupant of the requirem
requirements which most be et Q5
prior to Issuance of a Certificate of Occupancy. C��r`r 19
Owner or authorized agent Date 70TH L: ISSUED BY
OFFICE COPY