23931 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proic I Identification 7 PrIRMIT NO.
Building Address: 23931
/ �Sfa r �ri'tee�
mars ams. one: A A A
CITY OF CUPERTINO-BUILDING DIVISION
c°nfr tt.ra me: LIc.N°: APPLICATION / PERMIT
`� 5 BUILDING-ELECTRICAL-nU RING-MECHANICAL CATEGORY CONTROL N
Arehilec/Engineer. Lee.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:
['FRM9TISSUANCE ❑ ❑ ❑
LICF.NS ED CONTRACTOR'S DFions of haps
I her eby,(Uncathat lam0<m3 oftheerpessand sofessioer9de,and c APPWANCESRESIDENML JOB DFSCRB'TfON
Legwith Section 7000)0nd Division oltct. -hJe Buslneasand Pro(eaUonsC.de,and my
Lker.CBeer.Is lass 114 roe and)i.tl 3 03 S / PANELS
Data —Contractor -r
ARCHITECT'S DECLARATION JJ 201-1000 AMPS
at 1 understand my plana shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.Fr.
O
G
G
U Licensed Professional SIGNS ELECTRICAL cis ^ I '
<Zw OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC F/ria 6F�e
�.., Ilsereowing rafBrmthmiam exemptfromthed Proftt0/s License Law fort he �� �� T
'z O'@o following reason.(Semon 7 t to Bustessand Professions Code:My city it 1 pE
Fzsty swntywhich requlrnapemtittomrutrua[,alter,lmprove,demo0ah,orrepalr n'MP.METER ORI'OLE INS(.
<�1 anystmu mpr rto Rsbsuame,alsomqulrestheappBmntforsuchper tto POWER DEVICES
C 1 O floe a ergo°statement that he Is r licensed pursuant it the Pon 7000) of the E
3u, Contractors License Law(Couper9(commencing with Section 7000)of Divi. SWINIMING POOL ELECTRIC
sion3o(the Busteasand Professions Code)orthatheesexemptiherefromand l VALUATION
Yi the bases for the alleged exemption. My violation of Section 70315 by any
<
applicant for a permit sub)rca the applicant to a civil penalty dnet rrorethan OUTLETSSWITCHEBI7KTURES
five hundred dollars($SM. NEW RESIDENTIAL ELECTR
�1,as owner of the property,or my employees with wages as their sok —SOFT. STORIES TYPECONSTRUCTION
compensation,will dothe work and thestrutture Is not intended or offered for
sale(Sec 70K Busbies,and Professions Code:The Contract.(.License Taw
js$ does not apply to an owner of property who builds or Improves thereon,and
G whodces such work himseBor through his own employees,provided that such OCC.GROUIa RTS.UNITS
improvementsarenot Intendedorof(eredforma .1fhoweve.theWildingor TOTAL:
improvement es sold within one yearo(complelion,the owner-budderw(II have
11,q1turden of proving that he did not build or improve for purpose ofsali QTY, PLUMBING PERMIT FEE flAOD7ANR APN
I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to constmct the project(Sec.7094,Business and Profeselons Code:
The Contractor's License Law does not apply to an owner of property who
buALTER-DRAIN&VFM-WATER(EA)
Wilds or Improves thec
thereon, and who contracts for so& pWies with a
on,ntEt[[ad aBcenaedpunuanttothe Cmtmdorb License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B&P C for this mason
OUTSIDE F.Es
Owner DRAINS FLOOR,ROOF,AREA,CONO. SANITARY Y N
Date
WORKMAN COMPENSATION DECLARATION RECEIPT 0
CIiOOL TAX Y N
[:]I hereby affirm that I have a certificate of consent to uNreII.YTDRES PER TRAP S
l(- w
,or
certificate ofWorkers'CompecaaIr
entrance lurance or a certified copy, RECEIPT N thereof(See. GAS EA SYSTF2d1 WC.40ITILEIS
3800.Tab CJ PARK PEE Y N
Policyp� y—� GPS FA.yyy-1'EA7.OVFA4(FA)
RECEIPT
Cam anyr a�rL�1y�[/-/Vm BUILDING DIVISION FEES
BCertifled ropy Is herebyrnlau GRFASE/INDUSIRL WASTE INTFRC121MR PLANCHECK FEE
Bferti0ed copy V filed with the city ivpettion division.
CERTIFICATE OF EXEMPTION FROM WOR K ERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Thissecion need not becompleted 0the permit esfor.ne hundreddollan SEWER-SANITARY-STORM EA,200FT. Date Remi tit
($100)orless.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I cont that o the Person
in any mannerhe work so as to b co eesubjermit s Lto theuxi, —
1 shall not employ any person in any manner w an to become mbjec to the
WWATER SYSITM/TREATING
Workers Compensation laws of California.Date PAID
O Z Applicant
Z o NOTICE TO APPLICANT.If,after making this Cenifkate,of Exemption,you NEW RESIDENTIAL PLMB._SQFr Date Remi of
should beenure atlbpn to the Worker;C°mpnn ati°^provlamro of the Labor TOTAL:
V7 Code,you most forthwith comply with such provisions orlhes permit shall be `f
W > deemed revoked. 6U1 TNGE
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
ZI hereby af0rm that there es a construct.lending agency for the perform, ELECTRIC FEE
O anc,ofthe work for which this permit is Wood(See.3097,CIv.G TOTAL:
U Lender's NamePLUMBINGFEE
LL f Iendee,Address QTY. MECHANICAL PERMIT FEE
O W lmnifythalMvemadthbappllmtlonandstatethattheaboveinform tion MECHANICAL FEE
d isconec.Iagree to comply withal)dtyand county ordinances and state laws PFRMITISSUANCE FEES PAID:
>. W relating to building construction,and herebyauthorberepresentativesofthis
I— Z city to enter upon the above-menttned property for hespvclon purposes. ALTER OR ADD TO MECH.
— (We)agree to save,Indemnify an d keep harmless the City of Cu Perrino Date Reeeipttl
against liabilities,0dgmenta,cvssand expenses which may in any way accme AIR HANDLING UNIT LO 10."CFM) SUBTOTAL:
agai teaid Cl Inco a ceof the an ting dthls permit.
� AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature.(Applicant/ ..tract. Date EKITAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAURDOUSMA ERIALSDISCLOSURE
Will the applicant or future building occupant store or handle hacardous HEATING UNIT(TO 100,ODO SM
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date Reeei tN
Iicalth and Safety Cade Section 25532(a)7 HEATING UNIT(OVER loo,00D BTU)
Yes M No TO
Will the applicant or future building occupant use equipment.rdevices VENTILATIONFAN(SINGLERESID) ISSUANCE DATE
which emit hamrdous air contamicants as defined by the Bay Area Air
• Quality Management District?No BOILER-COMP OHPOR)00,0W BTU)
4 Yea N°
91
M1averead teeb.th& Tet Code,Sections
25505, 5533 and 255346.95.( BOILER-COMP 100,000 BTU) f9
the California Health&Safety Code,Smlore 75505,7593 and 25539.1 (P .+a,
understand that ifthe building does not currently have a tenant,that it is my NEW RFSIDENTIALMECH. SQFT 6�
resporuibility in notify the occupant of the requiremems which must be met ��
prior to issuance d a Certificate ofOmrpancy. �s / `^
Owner or auihonsd agent Date CS ✓llc6 9
TOTAL: ISSUED
OFFICE COPY