23877 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PERMIT NO.
Building Address: T `, ` Ot _1 23877
� ran acus: NJ iv m'IeC((J)J .
L!1M 6*I ptrj CITY OF CUPERTINO-BUILDING DI VISION
C Iracto' N ��Lqic.No: APPLICATION / PERMIT 612j.AaaA1L
Q SB.T7I 5 BUILDING-ELECTRICAI.PLUMBINGMECHANICAL CATEGORY CONTROL p
rchltect/Engineer, Llc.No:
QTY ELEC RICPERMIT FEE BUILDING PERMIT INFO
Address: PQthtIi ISSUANCE ❑ El ❑
LICENSED CONTRACTOR'S DECLARATION
I herebySectio 7000) f Division
fthe er provisiors ofBusiness
and13ro Chapter 9(co and nc.my APPLIANCESRESIDENTAL . JOB DFSCIf/j'j]pN
If...with in fan7IKtl)of Dl effect o(theButlnmantlProfaulonsCode,and my �yy
Ilunsele In full de((ect. PANELS
LkenseC ss LIC#
Date Contactor y/
ARCHITECT'S DECLARATION 2014000 AMPS _
MZ I understand my plana shall be used as public remrda OVER1000AMPS SQ.FT.FLOOR AREA $/SQ.FT
{y O
Licensed Professional SIGNSELECTRICAL
� < OWNER-BUILDER DECLARATION
n] WSPECIAL C1RCUfT/MISC
Zt,P Ihercbyafflrtntlutl em exempt from the Contractor's License Law for the _
ZR (allowing maaon.(Section 70715,Business and Professions Code:Any city or 1J� " I LTJ
OZ TFAIP.MEIT7I ORIOLE INST. J f�
county which rcqulrcsa permlttocowtruct,Alter, demolish,arrcpalr
logg anystmctuie priorm its Issuance,alsorequlresthe applicant for such permit to POWER DEVICES' / /JQ D
5 file a signed statement that he Is licensed pursuant to the provisions at the SO G+4, `/C..�
3µ� Contractors License Law(Chapter 9(commencing with Section 7000)of Dlvl- SWIMMING IDOL ELECTRIC
SOS sion3 of the Business and Pmfesslmu Code)orthat he la exempt therefromand _jectsN
Q the basis for the alleged exemption:Any ,violation of Section 7071.5 by any t'
applicant fora permit subthe applicant to a civil penalty a cad rc
mothan OUTLE7SSWITCI IESFIX7T]RFS
live hundred doll..($500.
I,as owner ofthe roc NEW RESIDENTIAL ELECTR SQPT. SfOIIIRS TYPE CONSTRUCTION
�n ❑ property,rty,ormy emture is nm
as/herrdole
cad for
In(S.70KBusdess ando the rk,andlonshe Code:
rehe Cor ended License Law
D dare(Sec.apply
to Business and Pro(mlom Code:The C improvos ra License Taw
don nossuchtoanownerolproughhisoromplWilds rimproovidedreoR.nd
a who doeeauchwarkhimsel(orthraugh hisownemploym,prwlded that such OCC.GROUT' RES.UNIT
Improvements arc not Intended muttered for sale.If,however,thebullding or TOTAL:
improvemen(beoldwlthlnamyearofcompIMl mthe owner-WRderwlll have
the burden of proving that he did not build or improve for purpose of sale.). QTY, . ,`. PLUMBING PERMIT FEE FLOOD-
UM APN
L as owner of the property,am exclusively contracting with licensed pQ4MITISSUANCE
contractors to construd the project(Sec.7044,Businessand Profession Code:
The Contractor's License Law does nor apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon,and who contracts for such pTjeds with a
crp-qactor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
L j I am exempt under Sec. B &P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N-
FEES
Owner Date RECFIPCa
WORKMAN COMPA dificON DECLARATION FDiTURFS PER TRAP SCHOOL TAX Y_ N
QI hereby affiork res that 1 have o Insure to of consent to copy thereof
or a RECEIPT M
38W ateo(Workeri ComPaevatlon]ruurana oracertllled copythereof(Sec. GAS EA.SYSTEM-1 INCA OUTLLTS PARKFM Y N
3600 Tab C.)rr(�I IO.3 4 7 `/ — RECEB'f s
Polirys [.{_//VV CAS IA.SYSTEM-OVER 6(EA)
Com env r� a CA E BUIL DING DI VISION FE ES
Certifie�py ct hereby filedwththe city GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy V filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA.XIOFT. Date Recel tN
RMsaedlon need not be<omplded i(the permitVforone hundred dollars -
($100)arlem3 WATER HEATER W/VENT/ELECTK ENERGYFEE Y N
Icertor that Its the person Ian the work so whichA.to
comeewbje Issued, —
I shall not employ any Person In any manner w ea to become subject to the WpTfR SYSTEM/TREATING
Worker Compensatfan L. of Califomla.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.Fr, Date Recei tO
Z NOTICE TO esub)eAM:IL aper rs'Co perntionhis 1pro is Exemption,you
F- should become subject to the Workers'Compereatlon provisions o(the Labor TOTAL:
W Code,you must forthwith comply with such provisions or this permit shall be BUILDING
LU C deemed revoked.
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby alfirmthat there Is a corutruction lending agency for the perform, ELECTRIC FEE
7 Z arm ofthe workforwhichthls permit is Issued(Sm.3097,CIv.C.) TOTAL:
U O P<ndse.Name PLUMBING FEE
LLF Lender.Addre.a QTY. MECHANICAL PERMIT'. 'FEE' MECHANICAL FEE
O W Imrtlfythatl have read thisappiaaboveinlornvtio
tlonand statethatthe n
IL is correct. correct.I agreeto complywith all city and county ordinances and date laws PERMITISSUANCE FEES PAID:
>. N relating to building nstruction,end hereby authonu representatives ofthis
(— Z dytoent upontha above-mentbnscipropertytorimpedlanpurposes. ALTER OR ADD TO MUCH. Date Recei NI
Me a to save,indemnify an d p harmless the City of Cupertino P
.gal abilities,' dg cats san xpenseawhlchmaylnenywayaccrue AIR HANDLING UNIT(TO 10,000 CFM)' SUBTOTAL:
al aid City en of Starting of this permit AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
wtLre of app cat/C tractor Dat IXHAUSTHOOD(W/DICT) CONSTRUCTION TAX PAID:
HATH DOVS MA RIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei tp
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
health and Satiny Code Section 25532(.)7 HEATING UNIT(OVER 100,000 BM TOT
Yes in No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haxa Hous a4 contamiea ata as defined by the Bay Area Air
Quality Management District? BOILER-COMP OPO'OR 100,0(10 BTU) `
IlYes No
ve read the Faze ous mAtenals requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BIL) ® Alifrnla Health&Safety Code,Sect lom 25505,25533 and 25534.1 B- P'a
understand that ifthebuilding does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.I7
responsibility to notly the occupant of the requirements which At be met
prior to issuance of a Certificate of Occupancy. JUN h
Ownerm.ulh.dzedagent Date Bim, �./�.yNCTItI(vu
' r
PETAL ISSUED"'�/✓-
OFFICE COPY