23473 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bu Oding Add.: Project Iden,if� vC PFltM1TN23473
nes come: Din.ae:4�
�J A
(f fo 1.�7ne: CITY OP CUPERTIN0.BUILDING DIVISION
Contact&.Names Lie.No: APPLICATION I PERMIT 7
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL CATEGORY CONTROL#
A IM giant. Llc.No: v
QTY ELECTRFC PERM FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE �'
LICENSED E°CONTRA ad,,p DECLARATION
I hthSy 070t)oi am Divsion3ofthe ugnessand PmfmionsCode, msc APIPLIANCESREAD L JOB DESCRIPTION
It..ISection force And dieon3oflhe Budnessand Pro(essioneCade,and rtry
LI..lelass force and effect.
Limn.Cian LIo.r
Date Contactor MPS
ARCHITECT'S DECLARATION I. AMFs
p�v97O l understand my plana shall be used as public records 1000 SQ.Fr.FLOOR AREA 8/SQ.FF.
IJ Licensed Professional SIGNS
G'6 OWNER-BUILDER DECLARATION
1 herebyaffirm that l am exempt from the Contractor's License[Asa for the
M70 Zfogawing reason.(Section 70315,Business and Professions Code:Any city or TGdP ORIOLE INST.
FM county which requires a permit to mateact,alter,Improve,demolhh,ar repair
anyatructure prior to its lutawe,also requless the applicant for such permit to TOWER DEVICES
file a signed statement that he a licensed pursuant to the provisions of the
GµH. Contractor's License Law(Chapter 9(commenting with Section 7DOD)ofDKr� VAI.UATIOt AO:! don3 of the Business and Pmfesslo.Cox.)mast he iaesmpt theref.mAAd SWIdABNG IDOL ELECTRIC
4o06.••7777 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHF&FIXTURES i Q O
applicant fora permit subjects the applicant to a civil peva lty of not more than 111
five hundred1,asoowndoler
of
he property,
NEW RESIDENTIAL ELFGIR SQ.FT.
�e ❑I,as owner of the property,or my employes with wages rue there sok _ STOIt1aEL5 TYPT N�itUCTION
compensation,will B.,dothework.andthestruaurebn d,Intendedcosseted or offeredLaw I N /], L — '\YI
O sale(Set 7046,Buelnsss and Prolemta Code:7he Cunlractora Llceae Law �— INAL I1
S does not apply to an owner of property who Wilda or impresses thereon,and G R
who does,such work himself or through his own employes,provided that such 2
Improvements as no[Intended oroftered forsale.If,howeveq the W ilding or TO
Improvementbwldwlthinoneyearofcomplello4theowner-bullderwRihave L
thee,-burden of provingthat he did em Wild orlmprove for purpose.fine.). QTY. PLUMBING PERMIT FE•E
LI L as owner of the property,am exclusively contracting with licensed DAT °
mntembont.mnstructtbe project(Sea7044,Buasessand Pmfeaslov Code: PERMIT ISSUANCE t�
The Contactor's License Law don Act apply to an owner of property who ALTER-DRAIN VENT.WATER(EA)
Wilds or Imprwes thereon, and who contracts for such ptojec,s with a
c ctr(q licensed Punuknt to the Contractors Line..Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LI r am exempt under Sec. B k P C for this reawn
OUTS1[IF FEES
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N_
Owner - Date RECmTN
WORKMAN
COMPENSATION DECLARATION FDOURES PER.TRAP SCIdOOLTAK Y N
❑I hereby affirm that I have a artlRrate of const si spy thereof
ora BBC=N
certificate olWorken'Compewtlonlnsuranama certeled copy thereof(Sec. GAS FA.SYSTEM-1 INCA OUTLETS awe PARK FFR Y N
3gOq Lab CJ
Voilrya - RECEIPT M
Com n GAS FA.SYSTEM-OVER4(EA)
Y BUILDING DI VISION .CS
Certified copy a herebyfurnished.the cid. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK PEE /al�
Certified copy a feed with the coy Inspection division. Ip
CERTIFICATE OF EXEMPT ION FROM WORKERS' GRE'ASETRAP PAID
COMPENSATION INSURANCE SKIVER-SANITARYSTORM EA 700FT Date 1 t#
TThlsaecttn need nu be completed lithe permit a Tosca hundred dollars
(810 mrafyth WATER HEATER W/VENT'/ELECTR ENERGY FEE Y
Ill Am
lathe person
thework fors W I thispertNj cLto theed, —
I shall nm employ any penan d any manner w s to become abject to the WATER SYSTEM/TREATING
Workere'Compenutlon Lawn of Glifornia.Date PAID
Cf Z Applicant
Z O NOTICE TO APPLICANT:If,after raking this Certificate of Exemption,you NEW RESIDENTIAL['LMB. =nFr. to ilteceipt#
Fshould become subjectto the WorkerCompensation provisions of the Labor OTAL:
N Code,you at forthwith mmply withauch provisloaorths permit shall be
j deemed revoked. BUILDING FEEr
W
G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby afftrmthat there b,a construction leading agency for the parforrry ELECTRIC FEE a
D Z aFceof the workfor which this permit is Issued(Sec.3097,Civ.Q _
U O lenders Name PLUMBING FEE _
IL F Leadeea Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW lwglfythatl havereadthisappliatlonand satethatthe above information ���
IL Lsmrnct.Iagreelocomplywith rue dtyand cruntyordicancesend state laws PERMIT ISSUANCE ` FEES PAID:
} N relating to building matactlon,end hereby authodzcrepresenatives ofthis
F Z city to enter upon thecabwcmentioad property for inspection purpose. ALTO OR ADDTO MECH. Date CCI t#
V Z lWe) to save,Indemnify and kap harAJes the City of Cupertino
agal I haas,judgmenta, Band spenss whlchmaylnanywayamus AIR HANDLING UNIT(to I0,0D0CFM) $UB OTAL:
ruga t dCayin cons a granting of lists permit.
AIR HANDLING UNIT(OVER 10,0MCFM) CONSTRUCTION T C
Igmt o p C t not Date ' IXHAUSTF1oDD(W/DUCT) CONSTRUCTION TA PAID:
AZARDOU�.RIALS DISCLOSURE ran
Will the applicant or future Ilding occupant store or handle hazardom ]iFATWC UNIT 10D,(00 BTU) Date RC CI t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the _
Health and Safety Code Section 75532(a)I HEATING UNIT(OVER i0effiD BTU) T
❑ Yea No
Weltheappllcaet orfuare Wilding oavpant use equipment ordevics VENTILATION FAN(SINGLE RESID) ISSUANCE TE
which emit hazardous air contanJa ata as defined by the Bay Area Air aB
lbly Ma agement District? BOILER-COMP(3H POR 100,0(0 BTU)
YY. No
have read the hazy ous materials requirements under Chapter G95 of BOILER-COW(OVER 100,000 BTU)
the CGllfom U Health A Safety Code,Sections 75505,75533 and 75534.7 APR.17 1992 '
underata ad that if the Wilding dos not ca ently have a tena nL that it is my NEW RESIDENTIAL MECH. SQ.FT
responsibility to notify the occupant of the requlremena which must be met
prior to Issuance MaCertificate of Occupancy. I CITY UI" G rim 1114V ( ?L
Owner or authorized agent DateTO ISSUED BY:
l
OFFICE COPY