23309 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification
Budding Address: - PERMITNO,
Jawy S�Alle- c,2 23309
• re ams: one: p
�[�H'1 CITY OF CUPERTINO-BUILDING DIVISION
cd, fir.Name: (j No: APPLICATION / PERMIT
• e `� O BUILDING-ELECTRICAL-PLUMBING- CATEGORY CONTROL N
Architect/Engineer. No: MLCHAMCAL
_ "QTY : ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add.,: PEIMTISSUANCE
LICP.NSEDCONTRACTOR'S DE RATION
IMrcby affirm that lam lkensed underprov ons ofChApt.r9(..c. MPLIANCESRESIDENITAL JOB DFSC ON
ingwlthS ion7000)of Dlvlston3ofthe Busine andProfesion.Code,andmy
license is In full fore and sliest PANELS �
Llcen s Lk.p ` `I
Date Comscior
ARCHITECTSDECLARATION MI-IODOAMIS
AM
0Z ]understand my pias shaBMueed upublic records. OVER 1000 AMPS - SQ.Ff.FLOOR AREA §/",/O.FT.
UG LED IN
Licensed Profeslanal SIGNS ELECTRICAL
6 OWI Am exempt
DECLARATION
�+ � SPECIAL CIl(CUIT/MISC
L, Ihereby a!llrmlhatlem exemptfrom the Contractor's License law for the
It
o qqqq
county owng
reason.imsa(Section Business and Professions Cade:h, tl or
�Zlpppp"q coantywhkh rcqulrceaperrtdttocorutruci,alley improve,demoWh,arrepalr TEMP. ORIOLE INSF. f(\�\�+. Q /!
Oanystructurepriortoiblssuance,also requlrealheapplicartforsuchpermit to POWER DEVICES DATE �+ z / 7
(� file a signed statement that he b licensed pursuant to the provide®of the
u, Contractor.License Law(Chapter 9(mmrrcntlng with Section 7000)of Div+-
�O� ston3ofthe Businessand Pw(esbrs,Code)orthathebexempltherefmmand SWIMMING IDOL ELECTRIC VALUATION'
let Mals for the alleged exemptlon. Any violation of Section IMIS by any UTLETSSWITCHFSFD(TURES 1 a•� �� (� •!�
appdcant for a permit subjects the applicant to a civil penalty of not more than `
flundred dollars(S50ILL
6
�n I,as owner of the property,or my employees with wages as their NEW RESIDENTIAL ELECTR_SQ.Fr.sole SfORIES TYPO CONSTRUCTION
compensation,will do the work,and the structure is net Intended or offered for
O sale(Sec.7044,Business and Professors,Code:The Contractor.License law
�$ does not apply to an owner of property who builds or+mpsovs tMnron,and OCC.GRO(11P RES UNITS
who does such work himslforthrough his own employees,provided that such —
improvements are not Intended oraffered fors a.If,however,thebullding or T
Impmvementbwldwithlnoneyearofcompleton,theowner-budderwlll have
t"rden of proving that he did not build or improve for purpose ofsleJ, dry. PLUMBINGPERMIT FEE FLOOD—ZONE APN
Lf I,as owner of the property,am exclusively contracting with licensed
contractors to construct the project(Sec.7044,Business and Professions Code: PERMIT ISSUANCE ..�•
TM Contractor.Llcenao Law dos not apply to an owner of property whopLTFR-DRAIN&VENT-WA'Rdt(EA)
builds or+mprwes e.thereon, and who comrade fou such posiwith a
cc ttJactor(s)licensed pursuant to the Contractor.License Law. FEE SUMMARY .
LII am exempt under See. B A P C for this reason BACK FLOW PROTECT.DEVICE
Owner Date DRAINS-FLOOR ROOF,AREA,COND. SANITARY Y_ N_
RBCEETN
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N
[]I hereby affirm that I have a certificate of consent to self-insure,or a RFIEI'f tl
ttdificateo(Worker'Compcmtionlsumnmoracertlfkdmpythereof(Sec. GAS EA.SYSIFM-1[NC.60[TILEI5 �-• PARK=- N
PYolis Lab C.) RECEIPT N
Policy Y
Com n (EA)
GAS EA.SYSTEM-OVER t(EA)Erd copy b herebyfamished.
BUILDING
D I VIS ION FE ES
❑Certified copy is(led with the city Ispectiodivlelan. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
URA
COMPENSATION INSURANCE
(fhbeection need not McompletedI SURApermit b!carona hundred dollars SEWER-SANRARYS 0RMEA2001T Date Rcmi Ptk
(SI I mriles.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Icertl(y/hat Nthe peHormanm of the work for which fhb permit is issued, — —
" I shall not smplo any person In any r ro u_tq p�subject to the WATER SYSTEM/TREATMG' PAID
ZI7 eW plicam Co on of ate_T.fI �•/y
Z 'NOTICE L _r NEW RES[DFN[IAL PLMB. SQ.FT. Date Recei f#
O NOTICE 7��M:IL after mak ng this Certiflote of Ezemptlon,you
F should become subject to the Workers'Compeiaation provbios ofthe Labor TOTAL:
W Code,you moat forthwith comply with such provisions orthb permit shall be
> deemed revoked. BUIL12IN
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
a.Z C FEE
Ihereby atfirmthat there b a construction lending agency for the perform TO ELECTRIC FEE
(�7 once r(the work for whkhthis perzNtb issued(Ss.3097,CIv.C.) PLUMBING FEE
O Iandere Name
IL F Lend&.Addre.. QTY. MECHANICAL PERMIT . „ FEE ,' MECHANICAL FEB
OW Imaitythatl have read this application and aatethattheaboveinformation
1 is correct.I agree to comply with all city and worry ordinances and elate law. I PERMIT ISSUANCE �' FEE$PAIa
} relating to building conttuctlon,and hereby authorise representatives of this
F W city to enter upon the above-mentioned property for lmpection purposes. l ALTFRORADDTOMECH. Date ROCCI IH
V — (We)agree to save,indemnify an d keep harmless the City of Cu pen loo P
against liabilities,judgments,costs and expenses which may in any way awme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against sal Ity In mesa uence oftM granting of fhb pemnit
AIR HANDLING U7(OVER t O, CFM) CONSTRUCTION TAX
Sg rc or ppll m/Contractor Dal — EXHAUs r HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WElthe applicant or future building ocropant store or handle hazardous HEATING UNIT HO I ,000 BTU)
material as defined by(he Cupertino Municipal Code,Chapter 93Z and the Date Recel t(1
I Iealth and Safety Cade Section 25532(a)2 HEATING UNIT(OVER 100,000 BTW TO
r-1YesON.
Will the applicant orfutum building occupant use equipment or devices VENT?LA7ION FAN(SINGLE REMO) ISSUANCE DATE
which emit hazardous air=is triennia as dented by the Bay Area Air
Quality Ma oageoao District? BOILRR-COMP OHP OR 10,000 BTU) P A I D
Fly. n❑No
Ihavereadthehazallouam terials requirements under Chapter 6.95 of BOILEIbCOMP(OVER IO,Otill BTU)
.M California Health h Safety Sections 25505,25533and 25534.I ''II 8 1992
and—land that ifthe builds do na cvrzenllyhvve3 tenant,that itbmy NEW RESIDENTIAL MECFI. SQ.I7 FEB j
rtpis,sb ity to not lfythe occupant of the requirements which most be met /a
prior to isCITY_().-
Owner
of a Certificate of Occupancy. - Ur laUYtH UIVU
Owner or authorized agent Date ,
ISSUED BY:
OFFICE COPY