23086 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PERMIT NO.
Building Address:
a"2--Z -7c 23086
to dole: - ane' '-
yd r IJ st {� a AI-K �A CITY OF CUPERTINO-BUILDING DIVISION A
C.ntraneaName: Lic.Ntx APPLICATION /PERMIT
Architect/Engineer. Llc.No. BUILDING[7,ECTRICA4PLUMBINC MLCHAMCAL CATEGORY CO OLI&7SS
-0- Itt -h.I'. ° IllICPERMIT PEI ' 1 'J'",.,-t BUILDING PERMI-TJNFO _
',QTY'' I , ELECTRFj_
Address: PERMITISSUANCE �) ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby.
ffiran
erebyofflent thnt lam licensed vnderprovtslona o(Chapaer9(mmmm MPLIANCFSRESIDENTIAL - JOB DFSCRR'TION
ingwith Section 7000)o(Dlvlslon3ofthe H.MGl nsand Protesslo..Cnde,andmy
license is In full force and effect. PAN13
License Chss Lich '
Dale Contractor
ARCHITECTS DECLARATION 201-1000AMPS
0.Z0 I understand my plana shall be used as public ceroids. OVER 1000 AMT'S
SQ,FF,FLOOR AREA S/SQ.FT.
� �j Licensed Pro(esslorul SIGNSELECTRICAL
6 OWNER-BUILDER DECLARATION OD SPECIALCIRCUTT/MLSC
'[
hereby aff,m that lam exempt from the Contra"ofs License Law tar the
po followingreason:(Section MILE,Business and Professions Code:Any city or
TEMP.METER OR POLE INS?.
county which requires a permltto construct alter,improve,pro ,demolish,ormpair
anystructure priento its asuance,also requireatheapplicant torsuch permit to
PJ ry file a signed statement that he is licensed pursuant to the provisions of the POWER DEVICES
Contractor's License Law(Chapter I(commencing with Section 7000).!Dlvl- SWIMMING POOL ELECTRIC
sion3olthe Businesaand Professlom Code)orthat heisexempttherefromand VALUATION —
O the baals for aIle alleged exemption. Any violation ofSection
out m by any Q OUTLETSSWrGHESFTXTURES
hehanpplicantfora ealleedexe ptithe applicantn4,violation
fSectio(70tm.ret tun
fiveh dreddollars($500). _SQ.FT. STORIES TYPO CONSTRUCTION
- NEW RESIDFNI7AL ELFGTR
�n I,as owner of the property,or my employers with wage as thele sale
_ m(Sec.7ion,Busiothe ness
and Pr andtheaw"e:TheCure is Contraintendctors d far sale(Sec. ppy to ainower ofproperty
Cobuild,Contractors License Law
$� docs not apply toan.wner ofpropeg who build�oylmp P and TT
VO/-9
who does
ments amnot meelfor edorof hhieownem1 sea, rovidedthat ildingh eLF.'
improvement
mprovement Issold Intended (arsiln,te. he mw0ve; deer ill have jp F
t p Men of previwithat he did net
fner-bulose of sale.). 1
al e�iurden o/pmvingthat he dm na bu0d or Improve for purpose of sale.).. QTY, .` PLUMBING'PERMIT FEE' AP
LI L as owner of the property,am exclusively contracting with Homsed PERMIT ISSUANCE
contractors to construct the projM(Sec.7044,Business and Professions Code:
The Contractor's License Law don not apply to an owner of property who ALTER-DRAIN&VEN7-WATER(G) PA TP
/ v
Wilds or Improves thereon, and who contracts for such Enajoe s with e
co ctor(s)licensed pursuant to the Contractors License Law. BACK FLOW PR07ECT.DEVICEt "'FEE$U Y .Y
LJ 1 am ice pt unAer Sec B&P C tar thio reason - OUTSIDP FEES
Owner s � Data/'l.TTy/G7 ' DRAINS FLOOR ROOF,ARG,CONE). SANITARY Y N_
7 WORK AN COMPENSATION DECD 10 RECEBrFM-
1. ❑I hereby affirm that I have a certlfimte o!eanaent to se -insure,or FD(TURES PER TRAP SCHOOL TAX Y N "
moo,LaIeot Workere'Comperuatlonlnsuranrcore rerti(kd (Se
ropythemofc. RE
GAS G.SYSTFM-1 INCA OUIL S - PARK FEE- Y 'CEEP M
3BN
PoIlry Y
�J ficyN a -
RECL(I'T M
GAS G.SYSTEM-OVER 6
Com any _ BUILDING DIVISION FEE
S -
�CertBled copy V hereby famished.
Certified copy b Ned with the city Inspection division. - CREASE/INDUSTRL WA INTERCEPTOR PLANCHECK PPyE�E .�+a
GREASC TRAP PAID 6J J Cy.xT
CERTIHGTE OF EXEMPTION FROM WORKCRS' _
COMPENSATION INSURANCESEWER-SANITAR RM G.HIOFT. Date Recei tlf
(Thlssection need not be completed if the P."t ix for one hundred dollars
($10))
I))m that in the performance of lhework(arwhlch this permit Is issued, HEAw/VENT/Eaztn: ENERGYFEE Y " Nsued, —
I shall not employ any person in any manner so u to became subject to the /TREATING
Workers'Compensatlon Laws of California.Date WATT _PAID
0 Z Applicant NEW DEN7IAL PLMB. Q.F . Date Remi2t#
Z O NOTICETO APPLICANT:If,after making lhIsCertlllote of Exemption,you
should become subject to the Workers'Compensation provisions.fabs Labor TOTAL: 6 3T
N Code,you mu at fol hwith comply with such provisions or this permit shallM N —,�
lU G deemed revoked.
0. CONSTRUCTION LENDING AGENCY SEISMIC FEE a Q
I hercbyafBrmthattherelsaw tru"ion leadingagency for the perlorrry TOTAL: ELECTRIC FEE
7 Z anc0 of the work"(or which this perMI le Issued(& Ca
c.3097,Civ,
U 7L 24 A:ZM-
O ander:NomaPLUMBING FEE
LL F Lender's Address - QTY. MECHANICAL PERMIT FEE''. MECHANICAL FEE
0 U I certifythal l have read this applimtionand state that theabovelnfarmrtlem
W Iscorrect.I agree to complywith all city,and county ordinances and state lawn PERMITIMLIANCE � �'^ FEES PAID:
} a relating to building construction,and herebyauthmWereprexmativesa(this
~ N city to enter upon the abovo-mentloned property for Inspection Purposes, ALTERORADDTOMECH.
? (We)agree to save,indemnify an d keep harmless the City of Cupertino Date ReeeipHl
V against liabilities,judgments,omteand expenses which may in any wayaccrue ' AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL'
against said City in c...equenm of the granting of this permit.
��/ AIR HANDLING UNIT(OVER 10,00CIM) CONSTRUCTION TAX
sigmmrearAp ntARDO".r t`� FxHAusnlooD(w/DucT) ' 'CONSTRUCTION TAX PAID:
HAZARDOUS occupant
DISC UR
Wial.,dppllm ntortuC.pe ft0dlngoidpICW,eo.paer9ehaaardous FIFATING UM7(TO 1Q7,000 BTU)cantDate Reed tR
Health and Safety Code SCupertino Municipal Cade,Chapter 9.12,and the
Health and Safety Cole Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) ?OTA
❑Yes M No
Wllltheappllcant or future building occupant use equipment ordev(ces - VENTILATION FAN(SINGLE RESID) .ISSIyA Cf PATE
which coat haaardous air contaminants as defned bythe Bay Area Air - A Uu
lBy Management District? MOILER-COMP OFIP OR 100,00D BTU)
Yea
• shave read the haza❑rJ N.aysledab requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) DEC�� O 'IJJ� '
the California H &
ealth&Safety Code, 7550.5,25533 and 75534.]
understand that the building does not currently have a tenant,that it Is my NEW RES]DEN77AL MECH. S'Q.I4.
responsibility to not ify the occupant of the requirements which must be met
h prior to lssun ace of a Certificate of Occupancy. - Uh CUYtt-IIliv {► /
CI I Y.
Owner or authorised agent Data ISSUED BY..
OFFICE COPY