23854 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project IdemlHcatlon PERMIT NO.
Building Address: 23854
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meName: h
one:
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GRIN ?7Aia.- �opn 7s,d'_/,,Z,�,R CITY OF( L"X:RTINO-BUILDINGDIVISION �y
Contratt 'e�N'am`e: <! sae.No: --APPLICAT16N /PERMIT 0x"---LZ
.� W BULLDINC 0,ECTMCALPLUMBING- CATEGORY CONTROL x
ne
Arohited/Engier. .Lic.No: MEC}LAMCAL
r. .. QTY ELECCRICPERMIT . FEE BUILDING PERMIT INFO
Address PERh4TI1UANCE �� /� ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION �LI\J
IherebyafA7000atlamllcmufthe BuprovlandPm Chapter9(mmmen APPLIANCGSRESIDEMIAL •� D B'TIOF
ingwlth Sectio irrm th of am liv n sed un er pressand s of C aloneCode,and my
license Is In full form and died. PANELS
License Class LIc.R
Date Contractor
ARCHITECTS DECLARATION 701-1000 AMPS
00 Z I understand my plans shallbe used as public records. OVER 10110 AMPS SQ.FT.FLOOR ARFA S/S'Q.FT,
Licensed Professional SIGNSELECTRICAL
LL OWNER-BUILDER DECLARATION `/
fii 6 SPECLILCE(CUIT/MISC
7a' a owingrasonnthatlam31.5,B from the Contractor'sLlrenx law lin os 3 ',
op
following reason.(Section 70115,Business and Professions Code:Any city or
TEMP,METER OR POLE INST.
� countywhlch rcqulresa permittoconstmct,alter,improve,demolbh,orrepair
OQ anymmtt mpr rtolds Wuance,alsorequlmatheappBmntlmsuchper ito )OWER DEVICES
V file a signed statement that he le licensed pursuant to the provisions of the
Contractor.License law(Chapter 9(mmmendng with Section 700D)of� Divl-
SWIMMING OOL�LECTRC
0� sixn3oftheBamesandPmfemloroCcds)orthathebexempttherefmmand V��AaaLL�UaATON
6 5 the basis for the alleged exemption. Any violation of Section 7031.5 by any, OUTLETSSWITCHFSFIXTURES O s.y
On applicant for a permit subpdathe applicant to a civil penalty of not morethan /1\
flue hundred dollars(x500). NEWRMDENIIALELECTR SQ,Ff', �+V
7 6 ❑I,as owner of the property,or my employees with wages as their sole STORIES TYPE CONSIRI1C770N
compessatlon,will dothe work andthe structure Is not intended or offered for
D sale(Sec 7044,Business and Professions Code:The Contractors License Law
doesnotapplytoa a owner of property who Wilds or improves thereat,and OCC.GROUP RFS.UNITS
who does such work himself orthrough his own employees,provided that such
Improvements are not intended oroffered for sale.If,however,the building or
improvement u sold within oneyearo(completlan,the owner-builder will have
tlr urden of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE HOOD ZONE APN
u L as owner of the property,am exclusively contracting with licensed
mntractoes to construct the project(Sec.7644,Business and Professions Code: PERMMIT ISSUANCE
ctar.
The Contractor's Llcenee law does nat apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon,and who comment for such pra)em with a
ry➢j�actor(s)licensed pursuant to the Contractors License Law. FEE SUMMARY
LJ I am exempt under Sec. B k P C for this reason BACK FLOW PROTECT.DEVICE
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Date RFC=M
WORK MAN COMPENSATION DECLARATION - FIXTURES PER TRAIT SCHOOL TAX Y N
❑I hereby affirm that I have•certificate of consent to self.Insure,ore f RECF7I'I'M
¢AifiateofWorkers•Comper tlonlmumnmoramnBiMmpythemof(Sm. GAS FA.SYSTFIN-I INC.40UILE15
!.`..• 380,Lab C.) PARK FEE Y_ N -
.. CAS EA.SYSTFMAVER4(EA) — R EIVEB
PollryN
' Cany BUILDING DI VI SION FEES
omFCentifliled copy b hercbytumbhed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certimfied copy ds filed with the dry inspection division.
CERTIFICATE OF IREMFF]ON FROM WORKERS' CREASE TRAP PAID
-
(This COMPENSATION INSURANCE SEWERSAMTARy STORM F.A.200FT. Date RCCi tN
se on need raw be completed If the permit ti for one hundred dollars
Will)or less.) WATER f-IEATET(yy/yENT/EI,gCTR ENERGY FEE Y N
I certifythat In the performance of the work forwhich this permit Is i eacg,
I shall not employ any person in any manner soas to become sub)ect to the WATER SYSTFAI/TREATING
Worker%Compensation Laws of Califom)a. Date PAID
O Z Applicant Date Recei tit
Z O NOTICETO APPLICANT:If,after making this Certificate of Exemplbn,you NEW RESIDENTIAL PLMB, SQFT.
Hshould become subject to the Workeri Compensation provisions of the Labor IOTA
V9 Codgyoumust/orthwithmmply Mthauchprovi.iovorthhpermitehallbe
W > deemed invoked. - BUILDING '�
W
C CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z Ihemby affirm that there is a moshvctlon lending agency for the perform, ELECTRIC FEE
arcs of the work for which this permit is Issued(Sec.3097,Civ.C.) ar'
U O lender's Name PLUMBING FEE
IL F Lender.Address QTY. MECHANICAL PERMIT. FEE MECHANICAL FEE
OW Icedi(ythat l have read thisappllmtionand stalethat the above Information
C boomed,L agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. N relating to building construction,and hereby authorize representatives of this
�- U) city to enter upon the above-mentlonM property for impectlon pu rposes. ALTER OR ADDTO MECH. Date RCCeI Ile
— (We)agree to save,IndemN/y as d kn keep harmlethe City of Cupertino P
against iiabilltie;' dgmera,mads a ad expenses which may l ray�yyccr)e AIR HANDLING UNIT R010,ODOCFM) SUBTOTAL-
against Ci co equen /7dg/e/gra n this pens Q/
AIR I-uNDUNc UNIT(OVER fD,000cr•M) - CONSTRUCTIO UBT
Signature of Applicant/Coniradmr Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfumm building occupant store or handle hazardous HEATING UMT(TO 100,000RM
crunudalaadefined bythe Cupertino Munldp.ICMe,Chapter9.IZ.,dths _ Date ReceI t
Health and Safety Cede Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTA
E]Yes ral No
Wilithe applicant or futurebuilding occupant use equipment ordevices VENTILATION FAN(SINGLE RESIDE ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Tisa lily Management District? BOILER-COMP FHP OR 100,000 BTU)
ti Yea (�I No p p�
/ haus read theh.th&Sal yCodeiaection 25505, 5533 aChapter.1 of BOILER-COMP(OVIA 100,(Xq-BTU) C y
the California if the building Safety Code, of curuntlyh ve atennd,that 1
t respoundetandthatn tifythoccupant not therequirements
have which must
It is or NEW RESIDENTIAL MECH. SQ.IT.
prior to
iissuace ofa the occupantoftherequirementswhich must be met v
prior to issuance ora Certificate of Occupancy. . .
Gb l yr �
Owner or authorized agent Data ISSIIIiD BY 'n I lf�V
TOTAL.:
OFFICE COPY