23548 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERNUT NO.
Building Addreu:: / 23548
C.1
e one:
w ase CITY OF CUPERTINO-BUILDING DIVISION �`� w
C ra iName; c.No APPLICATION / PERMIT J L
y BUfLDING-ELECTRICAL-PLUMBING-MECHANICAL CATEGORY CONTROL#
Architect/Englmer. Lie.Na;
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PER ITISSIIANCE ❑ '❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby afilm OM).fam Bcm3.ftheunder pemand of(nuiumChapter 9de,and e- AIPPLIANCFSRES/DENTIAL JOB DESCRIPTION
ii...i Section Innocent!
efelan3ofthe0uslnessand lProfeselon,Code,and my / r,
Lt.. Is In full form and effect PANELS
Llunea Clam LILN
Date Comnctar
ARCHITECTS DECLARATION 701-1000 AMPS
�mz I understand my plans shall be used as public records. OVER1000AMPS SQ.Fr.FLOOR AREA $/SQ.FT.
00
t+;d Licensed Professional SIGNSELECTRICAL
6 6 OWNER-BUILDER DECLARATION
z Ci SPECIAL CIItCiJIT/MISC
I hcrcby affirm lhatlam ezempt(romlhe Contractafs Llmrue law(mthe
ORB following reason.(Section 7031.5,Business and Professions Code:Any city or
GF'ty countywhichmqulresapert ttommtmct,alter,lmpmve,demolbh,orrepair T�P'MEIIR OR TOLE INST.
'4 .77 anystructure pricrto its issuance,alsoretulrestheapplicant forsuch permitto
5 ilk a signed statement that he Is licensed pursuant to the provision,of the POWER DEVICES
gaol^ Contractor's License Law(Chapter 9(commencing with Sedlon 7000)of Dlvl- SWIMMING POOL ELECTRIC
Non3 ofthe Business and ProfessionsCode)orthat he is exempttherefeamand VALUATION
athe basis for the alleged exemption. Any violation of Section 70713 by any OUTLETSSWITCHFSFIXTURES
O applicant for a permit subpdsthe applicant to a civil penalty of not more than
live hundred dollars($500). NEWRESIDENTIALELECTR SQ.FT. STORIES TYPE CONSTRUCTION
�n ❑L as owner of the pmperty,or my employees with wages as their sole
compensation,wllldothe work,andthe structure 6 not intended or offered for
ea
is(Sec.7614,Bugrance,md Professions Cade:The Contracroe.License Law
does not apply to an owner of property who builds or improves therron.and OCC.GR0117' RFS.IINITS
who doessuch work hlmmlf ortheaugh Msown employees,provided that such
Improvements are not intended moffered forests.If,however,thebuilding or TOTAL:
improvement 6sold withinamyearofcomp:dt mtheowner-bu0derwBl have
t11Rp:rden of pmving that he did not buOd or Improve for purpose ofsabJ. QTY. PLUMBING PERMIT FEE
LJ L as owner of the property,am exclusively contracting with licensed FT.00D ZDNE APN
PERMIT ISSUANCE
contracture to construct the project(Sm 7074,Business and Professions Code: C'�
The Contractors License Law does not apply to an owner of property who J
ALTER-DRAIN kVENT-WATER(EA)
Wilde or Improves thereon,and who contracts for such ptojects with a
cq=acioKe)licensed pursuant to the Contractwi License Law. RACK FLOW PROTECT.DEVICE FEE SUMMARY
Lj I am exempt under Sec B is P C for this ma.on
OUTSI UP FEES
DRAINS E.00R ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPTX
WORKMAN COMPENSATION DECLARATION FIXNRF_S PER TRAP SCHOOL TAX Y N
❑1 hereby filmorkers that I have o Insurance
nsura c of consent m op thears,mcf ora RECEIPT X
certificate Workers Compen,aHonln,unnamamrtlfled copy thereo((Sec. GAS FA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
3800,Lab CJ
Policy N 33 — RECEIPT N
CAS G.SYSIT7d-OVER 4(EA)
Co�mp�nvs" op BUILDING DI VISION Fr.ES
7 7Certi� copy he by th the cid. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
'tNT
Certified copy 6 filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WOR KERS' CREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 700F1• 'Date ReceI t#
(TM1ie.uctl.n need not be completed I(the permit 6 foram hundred dollars
(SlW)or less.) WATER HFATEi W/VENT/ELECTR ENERGYFEE Y N
I mrtlfy that in the performance of the work for which this permit ie 6eued, —
I shall not employ any peraon In any manner so as to became subject to the WATER SYSTEM/TREATING '
Workars'Campensatlon lawsof Coliforms..Date' PAID
O Z Applicant
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NE'W RE4DPN'DAL PLMB. SQ.Fr.
W DatC RCCCi Ifl
Hshould become subject to the Workers'Compensation provisions of the Labor TOTAL:
C Cade,you must fonhwilh comply with such pmv6lom.,this perrmtshall be
W > deemed revoked. QUIL12ING FEE
0 F3 CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyaffirmthat there(Sacomuction lendingagency(orthe perform ELECTRIC FEE
7 Z ance of the work for which this permi6 Issued ued Ckc.3097,Civ.C.) TOTAL:
U O Isnder.N.me PLUMBING FEE 9
LL f Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE '
OO Ian lfy that l have read this application and Nate that the above information
IL 6rorred.l agreeto complywith all eftyand county ordinance and Nate laws PERMITISSUANCE FEES PAID:
>. N relating to building construction,and herebyauthorlaerepregrativeso(this
I— en
Z citytote,upmtheaWm
ve- entireard property/m Wpectlonpurposes. ALTERORADD7'OMECH.
U — (We)agree to save,indemnify an d keep harrelem the City of Cupertino Date Receipt#
against llabilltk.,judgments,costa and expeneee which mayleanywayacaue AIR HANDLING UNI',CFO 10,000 CPM) SUBTOTAL:
against said City In consequence of the granting of this permit.
AIR I LANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Signature of Applicant/Contacior Date D(HAUS'r How(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applies nt orFuture building occupant store or he std Is hazardous BEATING UNIT(10 100,000 B11n
material as defiecd by the Cupertino Mu oldpal Code,Chapter 9.1 7,and the Date Recei t#
H,.Ith a nal Safety Code ion 75537(a)7 BEATING UNIT(OVER 100,000 BTU) TOTAL: o�.S
❑
Yd,I..
WBl the applicant o les re Wilding occupant use equipment or devices VENTILATION 17AN(SINGLE RESID) ISSUANCE DATE
which emit haxardous air contamimrets as defined by the Bay Area A6
Qua lily ManagemenlD tr,t? BOILER-COMP DEP OR 100,0M STU) � A
' n�t�{l Yn No !-0
IfIa VC read thehusmateda6 requirements under Chapter 6.95 of BOILER-COMP(OVEt 100,000 BTU)
the Callfomla I iealth h Safety Code,Sections 25505,25533 and 7:534.1
understand tytoecsIfy the ding
does not erequi,haveatenantthat b6 et NEW RESIDENTIAL MECH. SQ.Ff. IWAY 1.O 19
responslbdlhat If theb it occupant oft he mqulyhave whichmuat beset uY�N�E�n'1I tuD 5
pr r olssmnce ofaCertl ate Occupancy.
G',— 9 CITY prrur n1
r or author lid agent Date TOTAL: ISSUED BY:
OFFICE COPY