23688 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project ldenuficrtlm, i
,,/ PER!MIT NO.
/
Building Address: 11"12 stQ/ 7C6/ 6 23688
WalDAM
-
W" A/7 -e/I -p5(pZ CITY OF CUPERTINO-BUILDING DIVISION A A
Mpa
contra ° : Lk.Na: APPLICATION I PERMIT
aso n r S BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
CATEGORY CONTROL M
Architect/Engineer. Lice No:
QTY ELECTRICPERMIT FEE BUILDING PERMITINFO
Address:
PERh9TISSUANCE TR 1:1 ❑ 11LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am bearsed under provisions of Chapter 9(commmc- APPLIANCES-RESIDENTIAL JOB DESCRIPTION
uilwith Section 7000)of DiAkon3ofthe Buslnessand Prole w&Code,and my
LkenselC ng 11 f andLlc.#,31,035
, PANEL9
to ,/-�a a/- 9
Data Contractor r)r
ARCHITECTS DECLARATION 701-IOOOAMPS
GrcO Zp Iunderstand my pbrushal be used as public cords. OVERI000AMP5 SQ.FF.FLOOR AREA
m 11 o Licensed Professto I SIGNS ELECTRICAL
QN OWNER.BUILDER DECLARATION SPECIAL CIRCUIT/MISC
F, ] Thereby a(lirmthatlam exemptfrom the Contractors License law for the
0_ —
following reason.(Section 70315,Business and Professions Code:Any city or
Cf M 1a9 county which requiresa permit tocovtrect,alter,Improve,demolish,orrcpair TEMP.METER OR POLE INSC.
ZOG anystmmmpdortoibissuance,aLwrequi theappUa.tforsuchpermitto O file a signed statement that he is licensed pursuant to the provisions of the POWER DEVICES
Contractors License Law(Chapter9(commencing with Section 7000)of Divi-
slon3olthe Buslnemand ProfaselonsCode)orthat hebexempttherefromand SWIMMING POOL ELECTRIC VALUATION
6 $ the barb for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSW SWITCHES-FIXTURES
applicants nt fora permsubje tsthe applkant penalty not more to a civil pelty thin
µ �2 flue hundred dollars(1500). / 0
1 as owner of the property, y employees R NEW RESID A
< ❑, p perry,or m em to ees with wages as their sok STORIES TIE CONSTRUCTION
compensation,will do the work,and the structure is not intended or offered for
O ule(Sec.7014,Busbessand Professions Code:The Contractors Llce.Uw �1
$ does not apply to an owner of property who Wilds or improves thereon.and ✓ �� RIS.
who does such work hlmseB or through his own employees,provided that such OCC.GROUP UNITS
Improvements are not Intended oroffered forsale.1(howeveq thebuilding or
Improvement b sold within rneycarofcomplelon.the owner-bu0der will have
the*rden of Evening that he did not Wild or improve for purpose of sale.). QTY, -PLUM APN
LJ S as owner of the property,am exclusively contracting with licensed D]DNEPERMIT ISSUANCE
contractors to comtruct the project(Sec.7014,Businessand Professions Cade:
The Contractors Lio nse law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(E13)
Wilds or Improves thereon, and who contracts for such p(ojeats with a
mlLtrinner(g Bcensod pursuant to the Contractorb License Law. BAIX FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B&P C for this reason
OUTSIDE FEES
OwnerDate DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N
WORKMAN COMPENSATION DECLARATION RECEIPT#
❑I hereby affirm that 1 have a cenNcate of consent to self-inure,or a FIXTURES PER TRAP
SCHOOL TAX Y N_
mnlflateofwork Comper ion Insuranceofawftffwcopythemof(Sec. RECEIPTN
3 W INb C.) GASFA.SYSTEM-1 WCAOUTLEFS PARK FEE Y_ N_
Cam any n G R GAS FA.SYSTEMOVER 4(EA) BOILRECElpr#DING DIVISION FEES
❑Certified copy is hercbyth the d.city
GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
�Certifid copy b filed with the dry Irepection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Thlssectionneed not becompletd Bthe permit Marcos hundred dollars SEWER-SANITARY-STORM EA.200FI. Date Recei t#
(A00)er less.)
I certify that in the performance ofthework forwhlch this permit is issued, WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
I shall not employ any person In any manner so a to become subject to the
Workera Compensation Unva of California. Date WATER SYSTEM/TREATING
O Z Applicant PAID
Z O NOTICETOAPPLICANT:if,aker making thb CenBiuteof Exemption,you NEW RESIDENTIAL PLMIL__SQ.FT, Date Remi t#
Fshould become subject to the Worker'Compensation provisions ofthe Labor
WN Code,you mus:forthwith comply with such provisions orthis permit shall be TOTAL:
> deemed revoked. BUILDING FE•
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEB.
1 hereby affirm that there is a commiction kndingagency,for the perform
Z ance of the work for which this permit is Issued(Sec.3097,CW.Q TOTAL: ELECTRIC FEE
V O Lender's Name PLUMBING FEE
LLF Lenders Address QTY. MECHANICAL PERMIT FEE MECH
O W Irnnifythat l havereacithis appllutionand natethat theaboveinformation ANICAL FEE
d bn
coect.I agree to complywith al city and county ordinances and state laws PERMITISSUANCE FEES PAID:
r W relating to bulldingcowtmnion,andherebyauthod mpmwntativmafihb
Z city to enter upon the above-mentlond property for inspection purposes. ALTER OR ADDTO MECH.
V _ (We)agree to save,indemNfy an d keep harmless the City of Cupertino Date Receipt#
against liabilities,judgments,malsand expenses which rs In anyway... AIR HANDLING UNT(To 10,000 CFM)
ag.imt saki Ci Inco era oft antlers ofthls it. SUBTOTAL:
g� D
DLINGLINIT(OVERI ,000CFM) CONSTRUCTION TAX
Igu mof Ap sant/Conte r/ Dae Alok HOOD(W/13lsT CONSTRUCTION TAX PAID:
HA]ARDOUS AS F.RIALSDIS IOSURE
Will the applicant orfuwm building occupant store or handle ha>ardom UNIT(TO 100,000 BTU)
material.,defind by the Cupertino Municipal Code,Chapter9.17,and theDate Recel t#
Iie❑ai1 Y�d Ba(etyCde,Se Jloon 25537(.)7 HEATING UNIT(OVER 100,0008TLA TOTAL• �-
Will the applicant or fuNrebullding occupant use equipment or devicesION FAN(S1N'GLE RFSID)
which emit havaMous air contaMmnts as deflrsd by the Bay Arca AirI�UANCE�DATE
Quality Management D❑isMct7 MP PFI'OR 100,000 BTU) M II
91 Y,, d No
averead earthhe sir osis materials tions2rcntsunder Chapter. 1 ofMP(OVER 100,000 BTU) .��� a as ����
the Cali( rnLa Fiulth&SafetyCode,Sectlov 75505,]5533 and 75534. IVlunderstand that l(the building does not covently have a tenant,that It is myDENTIALMECH. SQ,FT
mspomibility to notify the occupant of the requirements which must W met
Priortoissuanu&aCenl Fiuteof Occupancy. yll'( Vr �a Urtfll'�
Owner or authonved agent Data
TOTAL: ISSUED It
OFFICE COPY