23894 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building
Adder: 23894
1(A91( MARCA �eL C
Wnm One: APPLICATION SUB9ffrXE=
11�a�F CITY OF CUPERTINO�BUILDINGDIVISION
contndnr,xame: Lm.No: APPLICATION /PERMIT
RVA, 10/1 313S-14n BUILDING-ELECTRICALPLUMBINC-MECHANICAL CATEGORY CO (a>}y.a
AmhltM/Engineer. Lie Na: tl....VV
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:sgme DCONTRACTOR'S
1 09
LICENSED CONTRACTOO R''SS DECLARATION PFRMITISSUANCE
I hereby SecionMthdlamsionsed 3 oftheunder provisions
essand Pro Chains 9(commrnc APPLIANCFSRESIDENTIAL JOB DESCRIPTION
Inis in
force a Division (theBus!nmand Prolmalona Code,and my ^^ /#3,�aa..�f
Licelicense le In(u8 force and et(en. PANELS Far) 1 m p
Date Cyan Cma
Date Contndor UP TO 200 AMIM
ARCHITECTS DECLARATION 201-1000AMPS
re0D 2 I understand my plana shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA 5/SQ.ET.
I�() Llccne d Pro(enloml SIGNS ELFLTRICAL
Z 'a FLr7 OWNER-BUILDER DECLARATION SpECIpL CIRCUIT/MLSCu a. ,
Iherebya(flrmthatlemexempttromthe Contndore Licence Lawfathe '(^as
qqQ (ollowingreason.(Sen1on7031S,Businmand Professions Code:An d or
Fcy cauntywhlchmqulmsapem twmmtmd,alter,lmpmve,demolbh,orrcpalr TEMP'METER OR POLE INST,
7 anystmnum prlorto its Lwance,aLw requltesthe appRnnt(onuch permit to
O �
file a signed aUrreV licensed that he cenaed pursuant to the provisions of the POWER DEVICES
n. Conlndor's License law(Chapter9(commencing with Section 7000)of Divi-
alon3ofthe Bualnenand ProfmlonsCode)orthathehexempttherefromami SWIMMING IDOL ELECTRIC VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any <7—
<5 applicant fora permit subjectatheapplicanttoacivil peraltyafnotnnrethan U7IETSSWITCHESEXTIJRES 7 S C
five hundred delta.($500). NEW RESIDENTIAL ELECTR P '1'IONa
❑ ECONSTRUCI,as owner of the pmperty,or my employees with wages as their sale SQ.FT. STOI(IES 7Y
compensation,win dothe work and thestructure la not Intended or offered for r I
p -1.(Sec.70K BuaNmsand Pru..m.Code:The Commetm's License law
does not apply to an owner of property who builds or Improves thereon.and
who doeearh work hlrruel(orthraugh his own employees,provided that such I - +� n fj'CjRQV1� ITS
improvemenbarc not Intended orotfered formic.lEhowever,thebuildlagor .w,Yl P11 lyl_J
,yen of
b sold within mayear ofcompletlon,the owner-builder will have
r't sen of proving that he did not build or Improve for purpose of Yale.). QTY. PLUMBING PERMIT FEE N _
as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE TE
co radon m construct the project(Sec.7044,Business and Professions Cade: -O
Conteador's License Law does not apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
Wilds or Improves theman, and who contracts far such `P1Pm a 11th a r FEE SUMMARY
cgElVacimexe cat under Sec.
the Contnciori Lk It PLaw. BACK FLOW PROTECT.DEVICE
LL1l l am exempt under Sac. B 4 P C for this mason
Owner DRAINS FLOOR ROOF, SANITARY Y N
Date RECEIE T#
WORKMAN COMPENSATION DECLARATION FIXTURESS PER TRAP SCHOOLTAX Y_ N_
❑I hereby affirm that I have a cettlBcate of consent to self-Inas,or a RECELFT i
01
Compensation lnsunnaara certl(led copythenof(Sec. CAS EA.S75TEN-1 INCA 3800,Iab CJ PARKFEE Y_ N '
Polity# — RECEIPT
Com GAS F.A.SYSTEM-OVER 4(FA)^Y BUIL ENG DTVI FEES
Certified copy is hereby furnished.
CertGREASE/INDUSERL WASTE INTERCEPTOR PLANCHEC -•E b Certified copy V(fled with
the
e cidty inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PA
COMPENSATION INSURANCE
(Thlssedre
ion need not he completed lithe permit is foram hundred dollars SEWER-SANITARY-STORM FA'XIOFT' ate Refei If
($100)ar len.) Y FEE Y I �—
Icemifythatlnthe pedarmanceotthework forwhichthis permit isissued, WAT�R}[FATFRW/VENT/FI'ECTR Qr 9Q
I shall not employ any person In any manner so as to become subjen to the WATER SYSTEM/TREATING `I #
Workere'Campenmtkm awaaf Gbfomla.Date PAID
C) Z Applicant
Z O NOTICE TO APPLICANT;If,after enticing this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQFT, Date Recet t#
Hshould become subject to the Worker Compermation provisions of the Labor TOTAL:
n Cod,you at forthwith comply with such provisions or this permit shall W BUILDING r,.
LU > deemed revoked.
O. c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there Is a corstructlon lending agency forthe perform- ELECTRIC FEE
M Z once.(the work(car which this permit is Issued(See.3097,CIv.C.) T
L) O lender's Name PLUMBING FEE �^
IL — leader's Aadmn QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I cennythat l have mad thisappocanonand statethat theabdve Information
a lacorma.l agree to complywith all city and county ordinances and nate laws PERMIT ISSUANCE /rCU FEES FAIR:
relating to building construction,and hereby authorize representatives o(this
F Z
city to enter upon the above-mentioned property for inspection purposes. ' ALTER OR ADD TO MECH.
V — (We)agree to save,indemnify an d keep harmlm the City of Cupertino Date Receipt#
18-lstllabl Ins,ludgmcua, sandexpenseswhichmaylnanywaya a AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against ryln cons a of tis anlin his permit AIRHANDLINC UNIT(OVER 10,000CFM) CONSTRUCTION TAX
/o �z9
g lu o Appll nt/C conn Dame EXHAU!iTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
FIAZ RDOUSMA 13RALSDISCLOSURE
Will the appBcent or(uture building occupant atom or hand le hamodous HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date Recei t#
Hrhh and Safety Code Sa.Hon 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑YeaNo
Will theapplicant o�tum buildlegoccvpant use equipment ordevlas VENTILATION FAN(SINGLE REBID)
ISSUANCE DATE
which emit bass rebus air contaminants as defined by the Bay Area Air
Qua llty Management District? BOILER-CDMP OFm OR 100,IX0 BTU) p,s
Yo n❑No P
have read the haaardouamaleriahi requircmnnb under Cha pier 6.95 of BOILER-COMP(OVER 100,000 BTU)
the Califomla I lealth k Safety Code,Sections 25505,25533 and 25534. I OCT
9
understa ca
rnd that if the building doetenant.
s net currently have a that It is my NEWRESIDENTIALMECH. SQ.FT. 1
p.r.ohnity to notify the occupa at of the requirements which moat be met r
prior to Issuance of a Certificate ofO=po ary.
Cl I Y ur cut,-t.(,�
Owner or authorised agent Date ISSUED BY
To
OFFICE COPY