23550 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro e"Identification PP MIT'NO.
Budding Address: 2� 23550
';&0Vnes arm: one:
Ig e or w, Cuiainj CITY OF CUPERTINO-BUILDING DIVISION c'
• Comtndora Name: Lica Non APPLICATION / PERMIT —\—Z—Asi
B(ALDINGELECTRICALPLUMBING-MECH LAICAL CATEGORY CONTROL Y
Aahlted/Engineer: Llc.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add.: P[RA9TISSUANGE
LICENSED Osmod under
n OR'Serpr DECLARATION O
ivith Syafarmthatlamlkeneefthe B.provblonsatChitio.C(rommenc- APPLIANCESRESIDENfiAL J01190IISCRRrrio..
InenseIIn fon 7000)of Dloffect otthe BuslndeandPro(esslonsCode,andmy �_ (!I
license Is In full fog and effect. PANELS
Llcen Clam �D LIc.N 6CQ672
Date B: Contranor (yap UP 10 2DO AM25
ARCHITECT'S DECLARATION 2014000 AMT'S LM
1Q+�rel Q❑ I understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.IT.
E O(/ Licensed Professional I SIGNS ELECTRICAL
fn OWNER-BUILDER DECLARATION SPECIALCIRCUIT/M15C - t �' 1
ZH, IherebyafflrmthatI am exempt from the Contractor's License Law for the I V
P4 ❑ following reanon.(Section7031S,Buslneeaand PmI.km.Code:Anydty or /-^1 i, /. _
!� county which rcquiresapermit tume tmct,alter,Improve,demolish,orapair TG5?.METRORroLEINSf. T ('
g anyatructure pdortoln Wuance,a horequireatheappdcantforsuchpermitto TOWER DEVICES �� ` I I�
PJ O F file a signed statement that he Is licensed pursuant to the provisions of the Qb y Contractor's License Law swMhuNcrootRLECRC AT
SOS smn3os he Business and exemption. Any
hion of exempt therefrom and _ 770N
O p5 the basis for the alleged exemption. Any violation of Section 70115 ni any OUTLETS-SWITCHES-FIXTURES
applicant fora.arms(subjede the applicant to a cavil penalty of nil more thin
.ACL` Ove I,aso owner
ofthepr. NEW RESIDENTIAL ELECIR
cope asowner l theproperty,ormy employees inwithended as offered sole _Si STORIES TYPE CONSIRIICTTON
sole(Sc.70K
dess ando the Prrl,andmes Code:Th Coot ntractortended or License
Law
O ask(Sc.7654.to a now owner
f property
Code: Contractors License law
5� whoddoes oessucht.pply toanownerofproughhis o nem oreproovideves thereon,and OCC.GROUP RES UNITS
whodoeseuch workhimself a throughhisownemployees,providedthatsuch
Improverrcntaarenot Intendedorof(eco !oleate,If,h ner-g deer ilingve TOTAL;
'unprovemant'swill withinoneycarolcompldlogtheowner-bullderwlllhave
(t(9jurden of proving that he dm not build or improve for purpose ofwle.). QTY. PLUMBING PERMIT FEE p DZONE ApN
LI L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
ce.micti n to.antruct the project(Sec.7044,Business and Professions Code:
The Contme or's License Law does not apply to an owner of property who ALTER-DRAIN AVENT-WATER(PA)
Wilds or Improves thereon, and who contracts for such paokM with a
cop[(actor(a)licensed pursuant to the ContracmYs License Law. BACK FLOW PROTECT.DEVICEFEE SUMMARY
I am exempt under See, B A P C for this reason
OUTS 1 UP F
Denner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N
RECEIPT p
WORK MAN COMP ENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y_ N_
❑1 hereby affirm that I have o certificate of convent to opy thereof
or RECEIPT Y
certificate of Worken'Comperuatlonlmurana ora certl(ed ropy themof(Sec. GAS EA.SYSTEM-1 INC.4 OUTLETS
Poli lab C.) t PARK FEE Y N_
Policy Y RECLB'T N
Com an CAS EA.SYSTEM.OVRR 4(EA) �..e
Y BUILDING DI VISION FEES
Certified copy ifiled with the
city
inspection division.
Is hercbytum
Certified copy la CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑ ty
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANffARY-STORM EA 200F1' Date RCCCI t#
(Thlsse"ion need not becompleted ifthe ps it forone hundred dollen
(SI00)ortess') WATER HEATERW/VENT/ELECTR ENERGY FEE Y N_
I certtiythat in the mance fthework rwhlch this permit Is Issued, —
I shad not employ at non 1 ny man r o d t ecome sy feet to the WATER SYSTEM/TREATING
Workers'Coon o Laws Ca[if
ate' 2- PAID
OZ Applicant NEW RESIDENTTALPLMB. Q.T. Date Refef t#
Z 0' NOTICE TOA? L .If,afternu Certificate of Exemption,you
should be..au othe Works eneotlon provisions ofthe Labor TOTAL:
N Code,you must forthwith comply wl suchprovbimu orthis permit shall be
j deemed revoked. BUILDING FE
W p CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL I hereby affirmthat thea 6 a corutmction lending agency for the perform- ELECTRIC FEE
Z. an.of the work for which this permit Is Issued(Sec.3097,CIv.C.) T ate'
C) Q la'dder's Name PLUMBING FEE _
LL I- Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Imrillythatl havereadthisappliohonan matethattheabovc lnliumenlon
bcoract.l agrato comply with all dtyand county ordinanmandstatelaws t PERMIT ISSUANCE FEES PAID:
} C relating to building comtructinn,and hereby authorize rcprcsentatives ofthb
1— N city to enter upon the abovnmenlloned property for lmpection purposes. ALTERORADDTOMECH.
Z (We)agree to save,Indemnify an d keep h rmlcss the City of Cupertino Date Receipt#
O agalretliabillliey}dements,mate and expene which maylnanywayaceme AIR HANDLING UNIT ITO 10,000CFM) SUBTOTAL:
agairutsaldC y Ir wqu mofthe ant epfth permit.
NR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTIONTAX
21 AZARDOUSM CONSTRUCTION TAX PAID:
Bigwtu t/Contractor Date EXHAUST HOOD IW/DUCT)
SDISCLOSURE _
Will the applicant or future ruin occipantste, hapten le hazardous FSFATTNC UMT(TO 100,000811])
material as dented by the Cupertino Municipal Code Chapter 9.12,and the -- Date RCCCI f#
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,00 BTU) TOTAL: �e
❑Yd N No
Will the applicant or future building occupant useequipment ordevices VENTILATION FAN(SINCLE RESID) ISSUANCE DATE
which emit haeurdous air contaminants as cleaned by the Bay Arca Air
Quality Management District? BOILER-COMP OHP OR 100,000 BTU)
4Yue
havercadthe h.2uNsomalerlalsreerylrcmentsunder Cha pier 6.95of BOILER-COMP(OVER 100,000 BTU) pp
the California Health k Safety Code,Sections 25505,25533 and 25534. I P 1' Gt
understand that if the building doll not currently have a tenant,that it is my NEW RESIDEf-MAL MECH. SQFTT. V
rnpornhility to nolify the oavpart of the requirements which must be and
prforto( uanceofa CertiticateofOmpancy. 1' qpR
19
Owner or authorized agent Data L,
TOT ssuEDe
OFFICE COPY