23227 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulldin Project ldemtlflaatloo PERMITNO.
Building Address: 2322
�f1^/"f
653 s'NAflo 3 L G I t c3 GAP i� �/Soi G
� one:I ` y nera Name: AFFLICADONwDATE
y�j—f�S,f CITY OF CUPERTINQBUILDINC DIVISION / � �
cantos SUBMITT
Lic.Nm APPLICATION / PERMIT r
BUILDINGELECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL a
A ��j
rchil nee, Lk.No: a
Qtt ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: t PERMITISSUANCE 1S:B0
PLUMB
LICENSED CONTRACTOR'S DECLARATION
hthb toflrmthat1ai 19.3.fthunder provLsldn ChapteC.d,amenc- APPLIANCES N]U BDESCRII'17UN
limnseh In fon force anDlvfect. otthe Businemand ProfemionsCode,acid my
license b In tun torte and effect. PANELSLicerV
Date Claes Lie/
Date Contractor
ARCHITECTS DECLARATION AMPS
oe l' !understand mypbreshallbe used aspubllcrecords. ER I"AMI SQ.FC.FLOOR AREA 8/SQ.FT.
00
�j Licensed Profamtarul SIGNSELECTRICAL
<ro OWNER-BUILDER DECLARATIONFI
f^�
Iherebyaffer,tb+tlam exempt(romnhe Contractor's License twfma SPECIALCIRCUIT/M 11 \1 _ I �
6 ooFyI p following reason.(Section 7031S,Business and Prolemlons Code:Any city or
Z ,–
P� � countywhich rcqulrcsa permit tocoratruct,alteq Improve,demolbhTEMP.METER OR POLE
,orrepalr NST. ^
q �a anystr =mpdortolb Wuance,aLwmqutrestheappBontforsuch perMtm POZIEVICES
3 0.U file a signed statement that he Is licensed pursuant to the provbiom of the
w Contractors License Law(Chapter9(mmmendng with Section 7000)of LTM- gWN4MING POOL ELECT'
O start Ioflhe Business and Pmfemlons Code)crthat he is exempttherefromaed VALUATION
the basis for the alleged exemptlon. Any violation of Section 7031-5 by any O w I OO
appli..tf.r.perm(tsubledstheappUcantt.advilpenaltyofnmm m ban 21 OUTLETSSWITCIiESHXTURES Y
p, five hundred dollars(RAO!. NEW RESIDENTIAL ELECTR
I,as owner of the property, SQJ.7. STOIIIES TYPECONSTRUCTION
p perry,or my employees Is next
with wage as their sole
E: d for
0
compensation,KwWdessand k.+sesiomnd the tructe:TheC ntcartintorde'oummeLaw
❑ sale(notap apply
Businessand Property
uC.ode:TW Contractor'sthc. Law
5$ does not apply to rk owner of property who Wilds or Improvm n Wreon,and OCC.GROUP RFS.AMTS
whodoementsa ntIntenedorough Msowne.If,ho es,pr thebthatsuch
Improvementsarenotintended earofco pl0io If,h er-g deer ilI have TOTAL:
Improvement bwld withlnoneyearofcompletiogtheowner-builderwlll have
tl[9J(u den of pmving that he did not bund or improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE FLOOD ApN
LI I,as owner of the property,am exclusively rontracting with licensed PERMIT ISSUANCE O
centractors to censbuct the project(Sec 7044,Business and Prolemtom Code:
The Contncmre License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER ffNN
Wilds or Improve.thereon, and who contracts for such Inpites -
with a FEE SUMMARY
ould 'torWheensed tmuanttothe Contract—or's LlmnseLaw. BAER FLOW PROTECT.DEVICE
Ll l am Is c. B k P C for this reason
O%v'fir Date DRAINS.FLOOR ROOF,AREA,CON I, SANITARY Y_ N—
C SATION DECI.ARATIO RECEIPT a
OI hereby affirm that I have a.Kifiote of consent io self-insure,ora FWTURES PER TRAP Qa pp/ SQi00l TAX Y_ N_
rertlflceteofWorkem'Compev tlonlro mnxoa¢rtlf4 ropythereof(Sec. RECEIPT/
3800,LabQ GAS EA.SYSTEM-1 INCAOUPLETS PARK FEE Y N
Policy p GAS EA.SYSTEMd OVER 4(EA) RECEIPT N
Com any BUILDING DIVISION FEESM
�Cedifid copy is heed with hecit. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE 11��
OCertlfid copy b filed with the city Inspection division.
CERTIFICATE OF EXEM PTION FROM WOR KERS' GREASETRAP PAID
COMPENSATION INSURANCE
Rhlssedionneed not becompleted ifthe permit bforom hundreddollars SEWEF SANITARY-STORM EA.200FT. Date Recei t#
(81lunileth WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
!cert iess.)t lothe performance olthe work forwNch thispermtla bared, —
I shall not employ any person In any manner w as to bemire subject to the
0 Z Applicant ' WATER SYS7TIN/TRGI]NG 1
Workers'Compensation laws.(California. Date v0 PAID 6
�3 �i
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB._SQFT, a Re i t#
should become subject to the Workers'Compensation pnevislom of the Labor
VT Code,you most forthwith comply with such provisions orthb permit shall be
W > deemed revoked. BILDIN •E
a E CONSTRUCTION LENDING AGENCY SEISMIC FEE �+
= Z Ihereby aft hat there ba construction lending agency for the perform. T AL .S9 ELECTRIC FEE 3
onceof the work for which this permit b Issued(Sec.3097,Civ.CJ
VO Lenders Name PLUMBING FEE 5, 3'
LL 1= Lender's Address QTY. MECHANICAL PERM! FEE MECHANICAL FEE
O W Icertifythat l have read thisappnotlonad statethat thesbove info mution
a broingt bagree ng Comply with alnd andereb county thommordthances
ropreseand Rate laws PERMITISSUANCE 004
FEES P�pFID,. _ �--
T N relating to building construction,and hereby authorize represenmivnofthis
r Z city to enter upon the aWve-mentioned property for Inspection purposes. ALTER OR ADD TO MECH.
V _ (Ne)agree to sa e,Indemnity an d keep harmless the City of Cupertino Receipt#
against Intl dg nts,mR,.ndexpenseswhichmayinanywayaame AIR HANDLING UNIT(TO 10,000 SUBTOTAL:
d 'y sequenceofthe granting of this permit.
rZ. 'YZ AIR HANDUNc uM1Tr( ) CONSTRUCTION TAX
/ re I lit/Cgmmet., Date EXFIAUST HOOD(W/D T) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occv pant store or handle haeadous HEATING UMT(TO 100,000 BTU)
materials,defined by the Cupertino Municipal Code,Chapter 9.1 7,and the Date Reeei t#
I lealth and Safety Code S4ction 25537(a)I HEATING UNIT(OVER IM BMW BTU) OTAL:
O Yes No
Wiiltheapplicar re building occupant use equipment or devices VENTILATION rAN(SINGLE REBID
which tohamdons air contaminants as defined by the Bay Area lib ISSUANCE DATE
Quality ManagementYeagiyrictl BOILER-COMP(3FR'GR 100,000 BT MAR 23 899
- I�I have
PAI.,?
a�
haveread theh et mode,Sorionsrc5entsundernd 2554. 1 of BOILER-COMP(OVER 1(O,000B Ciir Uf G
the Glifornla leap &Safety Code,Sod 2550.5,25533 and 25534. [ �a CUNt
uMerstan at if a ildingdo notmrmntlyhaveatenant,thatitbmy NEW RESIDENTIAL MECH. _SQ,FT. f7111YIJ
roporui 't t the occupant of the requimmxnts which must be met
ri rt f Certificate of Occupancy.
z3e yz gl�YlLaT//1
r o d agent Date
ISSUED .
OFFICE COPY ,