23333 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: 23333
wrens ante: r
I re:
/'�1�p A/�)��� ����j CITY OF CUPERTTNO-BUILDING DIVISION A I ,�. Ate./
.� Co sacra Name: —T'-- Lic'No, APPLICATION 1 PERMIT Z— l L
Architect/Engineer. Lie.N. BUILDING-ELECTRLCALPLUMBING-MECHANICAL CATEGORY CONTROL#
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Adtlrcan:- PERh17T ISSUANCE ❑ EJ ❑
LICENSED CONTRACTOR'S DECLARATION
I herebyaffirmthat lam Rcensed under proauters of Chapter 9 Immanent, APPLIANCES-RESIDENTIAL JOB DESCRIPTIONingwilh Sedion7000)of Dlvision3 ofthe BuMmmand ProfenionsCode,and my
license is in full farce and effect. - PANELS
License Class Lic.#
Date Contractor UP IQ 2DO AMPS /
ARCHITECT'SDECLARATION 701-1000 AMPS L
q�q�uu ceO Zp I understand my pians shall be used as public records. JOVERIODOAMPS SQ.FT. R E/SQ.FT.
Fi�() Licensed Prodesslanal SIGNSELECTTUCAL
<;<FS OWNER-BUILDER DECLARATION SPF-CIALCIRCNT/MISC
ZL, .7 1hereleyaffirmthat l am exempt from the Contractor's License law for the
following reason.(Section 70715,Businessand Pmfesdons Code:Any sty or
O TEMP.METER OR POLE INST. --
r county which requires permit toissuance,construct,
equtreatheaImprove,
nt forsch,ermit to
any a signere prior tatemeits that he
lice sed pursuant the (oreuch permit to
O � file a signed statement that M Is licensed pursuant to the provIslors of the IAJWER D CES / _ i_• I
Contractor's License Law(Chapter 9(commencing with Section 7000)of Dlvi- SWIMMING I'(70L r'—'
ston3oftheBusiness and Pmfesslo.Code)mthat he is exempt therefromand F�.ECTRIC'�
j' j , VALUATION
...]]] the basis for the alleged exemption. Any violation of Section 7071.5 by any
G appllontfora permit subjectsthe applicant to a civil penalty of not more than OUILETSSWITC}{FT.FIX'NRES
fivtundred dollars(faOO. NEW RESIDENThAL ELEE STORIES TYPECONSTRUCTION
�m I,as owrar of the property,or my employees with wage as their sole _
ce creation,wthdothe work and the sim=m Is net Intended or offered for
�� sale(Sec.9044,BusNessand l'rufessbre Code:The ContractoreUrerse law
$ does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP RFS.UNITS
who does such work himself or through his own employees,provided that such
Improvements are not Intended oroffered forsale.If,hmvever,thebuildingor TOTAL:
improvementIswldwithlnoneycarofcompletioMthe owner-bullderwlllhave
tfajZurden of proving that he did not build or Improve for purpose oFsale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed �^
cormuters to corsPERMIT ISSUANCEtrud the project(Sec.7044,Business and Professions Code: `l (�
The Contractor's Lt...law does nat apply to an owner of pmperty who
buALTERDRAINk VENT-WATER Wild.or Improves thin.,thin. and who contractssu
for such p,jed -
a with a (RA)
5drill licensed pmauant to the Committees License Law. FEE SUMMARY
I on exempt under See. B k P C for this reason BACK FLOW PROTECT.DEVICE
OUTSIDDRAINS.FLOOR ROOF,AREA,COND. SANITARY Y N�
I • Owner EC RECEIPT#
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAX Y N
❑I hereby affirm that I have a certificate of consent to self-Insure,or a 6�•0� RECEIPT#
ceniflnte of Workers'Comperwtlonlrourance ce a certified copy thereof(See. CAS EA.SYSTTM-1 INCA Ol711-EL'S
3800,Lab CJ - PARK FEE Y— N_
Policy# RECEIPT#
Com GAS EA.SYSTEM-OVER 4(EA)Y BUILDING DI VI SION FEES
Certified copy Is herclryfuMehed. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
Certified copy Is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WOR KER S' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.7 Err. Date ReceI t#
(Thissection need sea 4 complcted I(tM permit Is(Drone hundred doliare
($100)or less.) WATER HEATER W/VENT/D.ECTR ENERGY FEE Y N
I certify that In the performance of the work for which this permit is Issued, —
I shall not employ any person In any manner an es to become subject to the WATER SYSTEM/TREATING
O
Workers'Compensation Laws of California.Date PAID
Z nCnt
NONEW RESIDENTIAL PLMB. SQFf. Dale Recei t#
Z Q NOlicaAPPLICANT.If,after making this Certificate of Exemption,you
Fshould become subjedm the Workers'Compensation provisions of the Labor TOTAL:
CC N Code,you must fonhwith comply with such provIslom or this permit shall be
j deemed revoked. BUILDING '
LUCONSTRUCTION LENDING AGENCY SEISMIC FEE
I hembyaffirmthat them Is a mretrualon lending agency for the perforn ELECTRIC FEEo
Z ance ofthe workforwhichthls permit is issued(Sec.3097,CIV.) TOTAL;
U O Lender.Name PLUMBING FEE a0
LL H Lcedcr§Address QTY MECHANICAL PERMIT, FEE MECHANICAL FEE
O W Icertltythat]bve rcadthIs application and date that the above Information PPP���III
a Ie correct.building comply with allcityauthorize
inancesrepress and gate PERMRISSUANCE EES b
} W relating to building rorotmctlon,and hereby authotlu rcprenntatives of this L- 66 Y>
(— (A city to enter upon the abovo-mcelioned property for lmpealon purposes. ALTERORADDTOMECH.
(We)agree to save,indemnify an d keep harmless the City of Cupertino Dae Receipt#
L) againaliabilities,judgments,costs and expenses which may In anywayacerue AIR HANDLING UNIT CIO 10,000 CFM) SUBTOTAL'
agai Id itylnmnsequenceofthegrntingofthlepenmlt.
AIRHANDLING UNIT(OVER10,000CFM) CONSTRUCTION TAX
gm eof Applcmt/Contractor f I Date FXHAUSTHOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS CLOSURE
Will the spplicantorfuturebifichegotxupan smmorhamdleha:ardous HEATING UNIT(TO 100,000 BTU) Date Recei f#
material as defined by the Cupertino Municipal Cade,Chapter 9.17,and the
Health and Safety Code Section 75537(a)? HEATING UNIT(OVER 1170,000 BTU) TOTAL: 4�Q
F1 Y. r�No
Wllltheapplicant orfsware ilding.pantumequipmentordevicm VENTILATION FAN(SINGLE RESID) ,y$${JAVGP DATE
whlchendt hamcdousalrcontaMmntsasdeRred bythe Bay Area Air {s A 1 Er
Quality Management District? BOILER-COMP OHP OR 100,0(10 BTU)
4YNo
l have read the hazer ous materials requirements under Chapter 6.95 of BOILER.COMP(OVElt 100,000 BTU) ^�� A q(Y(lO
the Celifmrnla Health kSa(ety Code,Sections 7550.5,75573 and 7x534.] r Y. Is7 s7L
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL.MECH. SQ.FT
rrepmsibllity to not ify the occupant of the requirements which must be metCITY wrL'
411 INV
prior to issua nce of a Certificate of Occupancy. r
� I
Owner or authmdzmdagent Data ISSUEDBY: �U C.
TOTAL:
OFFICE COPY