23959 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BuildingProject Identification PERMIT NO.
Building Address: 23959
1a 5 iI
Owners arae: one;
CITY OPPLICCUPERTINO-BUILDING
PER DIVISION 1 D�Z
Co tr ctor'eName: � LIc.No: APPLICATION /PERMIT 7— D
BUILDIN6ELECTWCALPLUMBINC.MECHAMCAL CATEGORY CONTROL#
A hitect/Fsglneer. LIc.No:
QTY ELECTRIC PERMIT PEE BUILDING PERMIT INFO
Addmm: PENUTISSUANCE I fel ❑ ❑
LICENSED CONTRACTOR'S DECLARATION LPJ
I hereby affirm that l am licensed under provisions of Chapterg(crournme. APPLIANCES-RESIDENTIAL J BDESCRIPITON
Ingwlth Sedion7000)of DiAsion3oftthe Busiinmm^sa'n�nddP-offeessl�onsCode,and my
Dae lxn IIf eARCNIT'E[TS DECLARATI• ON L(C't UP TO
X711
�/,( 20140DO AMPS (�
9z f understand my plans shall be used as public record•. OVERI"AMPS SQ.Fr.FLOOR AREA $M.Fr.
Fi b O Licensed Professional SIGNS ELECTRICAL
<6 OWNER-BUILDER DECLARATION D I N
In] SI'ECIALCIXCUIT/MISC
gr'"' owinbyaEnnlhalon 7031mplfromthe Contractor's License Lw for the /�
02:H�Pr: county gremonArtfulness emeftw onstrusand Professions Code:Anyr pair A P UTE R
TEMP.METER POLE INS[. ,
�E .wystm mpriulmapmamt alsonq irntheapnvgdemolleh, er ttr
any a signeretatemeltshatt he
licensed
pursuant to
the
provisions
to POWER DEVICES
IIIc a signed statement that he 6 Ikeaed pursuant to the proWloa of the
Gw Contractor's License Law(Chapter with S
ng wection 7000)of Divi- DAT
I. t9( SWIMMING POOL ELECTRIC
t1u ba.i f.rthe ..IIegmass nd Professions Code)orthathebecctio. 03LS by and �' "" O eo
Pi O S the bash for the alleged exemption. Any violation of nactbn not1.5 ne any OUTLETSSWITCFIE2EXTURES �•• 2$-1 1 Ins
applicant fora permit subject the applicant toe civil penalty of not more than ` J {�
$ fi e,u f,undred dollars(5500).
1,as owner ofthe property, NEW RESIDENTIAL ELECTR SQ,Ff, STORIES TYPECONSTRUCTION
�n p perry,or my employen of in wages r 1Mh sole
compensation,wWdothewwk,andthe Codunhnot Intended orofferedL w
Odole(See 7044,toBeuencee
ow and f property
rops oat Cade:The Contramla License Law
$ donnaapply toahiw torch prtywhobuild.or nempleym,pvnthereoA,and OCC.GROUP RES UNITS
whodoese rds are k himse dad orwgh hisawn employers,provided thatauor
Improvementi arenotintendne)varfcomroffered oletior thelihowevepilderill have TT
Improvement hsold within oneyearolcmnplelion,the owner-bu0derwill)use
t"rden of proving that he did nal build or Improve for purpose oftele.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
u L as owner of the property,am exclusively contracting with licensed PERMITISSUANCE
contractors to ancrod the project(Sec.7044,Buslnem and ProfemWm Code:
The Contractor's License Law don no apply/o an owner of property who ALTER-DRAIN&VENT-WATER RN
Wilds or Improves thereon, and who contracts (or such ptnjects with a FEE SUMMARY
cgRilad.(s)It...d pursuant to the Contractor's Llcanec Law. BACK FLOW PROTECT.DEVICE
u I am exempt under Sec. B&P C for this reason
DRAINS.FLOG BOOP, SANITARY Y N=
Owner Data R AREA,COND. RECER'f p
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TIM' SCHOOLTAX Y N
❑I hereby affirm that I have a certificate of consent to eel!-insure,ora RECEIPT N
certificate o/Workers'Compensatlon Laurance ora certified copythenof(Sec. GAS F.A.SYSTEM-1 INCA OUTLETS PARK FEE Y N
38M Lab C.) �I/� tt //yy —
Paliry# eie:��O Y�' �11 GAS F.A.SYSTEM-0VER4(EAI RECEIPT#
Com an� {Q �y BUILDING DIVISIO Fr.rs
CA
copy6hereby fumlehed. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
®Cedlfled copy 6 filed with the city Inspection division. `
CERTIFICATE OF IXEMPIION FROM WORKERS' GRFJSITRAP PAID
COMPENSATION INSURANCE SEWER•SANRARY-STORM EA.200Fr. Date ecel [N
(rhis section need nut be completed if the peraut h for one hundred dollars
WATER HEATER W/VENT/ELECTR ENERGY FEE N
I cedily that in the performance of the work orwhlch this permit is issued, se
I shall not employ any person In any r n a to become subject to the WATER SYSTEM/TRPATING s
Worken'Compensatlon Love om6. Date I AID
O Z Applicant NEWRESIDENTIALPLMB. SQ.F. to Retei t1
Z O NOTICE TO APPLICANT:If,a(ter making this Certificate of Exemption,you
HN should become subject to the Workers'Compeaatlon provisions of the Labor ' TOTAL:
cc Cade,you at forthwith comply with such provisions or this permit shall be IL FEE
if G
7 deemed revoked. au
a (] CONSTRUCTION LENDING AGENCY SE FEE !
I hembyaf0rm that there 6 a constructionjIgedinglijePncy/or the perform- EL IC FEE
7 Q (se
ance of the work for which this pe rMt edc.3097,Civ.C.) TOTAL:
U nder'•N.me PLUMBING FE
F I<Ader's Addnaa QTY. MECHANICAL PERMIT FEE
OW lmdlfylhatlhavenadth6appbmtlonandetatethattheabovelnf.m don MECHANICA FEE
C bmrred.I agree to comply with a8 city and county ordinances and state laws PERMrr ISSUANCE FEES PAID:
>. relating to building comtrodion,and herebyauthorkenpnsntativesofthls
N
H citytoenterupon theabove-mentioned property for Wpecllon purposes ALTER OR ADD TO MECH.
V ? (We)agree to save,Indemnify an d keep harrelea Date Reeel 4M the City o/Cupertino AIR HANDLING UNIT against liabilities,judgment.,costsandexpenseswhlchmeyinenywayaccrue (TO 10,000 CFM) UBTOTAL:
agalnsbald City In consequence of the granting of this permit. AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTI TAX
Slgsatumof Appllcant/Contractor Data IXHAUSTIIOOD(W/DUCT) CONSTRUCTION X PAID:
HAZARDOUS MATERIALS DISCLOSURE _
Will theappllcant.1feture building oaupantstarear handle hazard... FfEATING UMT(T0100,000 BTU) Date Re tN
mdedal as deftned by the Cupertino Mu Ndpal Code,Chapter 9.17,and the
Health and Safely Code ion 2532(a)7 HEATING UNIT(OVER 100,000 RW TO L
❑ Yes N No VENHLATIONFAN67NGLERESID)
Willcthe apparent afuturebuilding as define by the Bay Area
it ISSUANCE DA
l)
which eManft aemnt District?ir contaminants as defined by the Bay Area A4
halley Management DhMct7 BOILER-COMP PFI'OR 100,000 BTU) �g p
Yrs No u PSI 8
havn read the Fara nuc materials requircmenb under Chapter 6.95 of BOILER-C'OMP(OVER 100,000 B'IU) �-
I the California Health&Safety Code,Sections 25505,25533 and 25534.I I
undentacad that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT
respoaiblllty to Anally the occupant of the mqulremenle which .at be met 'JUL
prior toissuanceof a Cel IRcate of Occupancy. s _
era k' rlred agent �/ TJa - ,t t r �Cf1111VV
to ISSUED BY:
TOTA4
OFFICE COPY