23449 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pmect Identification PIILMIT NO.
Building Address:
23449 .
wners one: A
came Q" 37S'zLIf CITY OF CUPERTINO-BUILDING DIVISION
hdMk Cn tra ora Name: Lie.No- APPLICATION I PERMIT
BUILDING-ELECTRICALPLUMBING MECHAMCAL CATEGORY CONTROLL
p
Architect/Engine.y Llc.No '
fl S I�E QN Vf e(✓ it,
gry�'l t ELECTRIC PERMIT, t)
FEC '�tt= 'BUILDING PERMIT,BINFO,
Address: (.tp n�j 3 Q PERMITISSUANCE !- -E ,. . .D E ,
LICENSED CONTRACF 'S DECLARATION - L(J
I hembysffirm that l am licensed under prwedons of Chapter9(comment, "APPUANCESRESIDENTIAL OB pp
ingwith Sccilon7W0)ofDlWaon3o(rhe Buslneesand Pm(eselonsCode,and my /1 LI -r Km '
license le In fuyy d effect. PANELS �Y�T(
Date
wmL,_ Co.d 375
Date Contactor UP TO 200AMPS - 0
ARCHITECTS DECLARATION XII-10MAMPS
NO O I ucda.t..d my plans shall be used as public records' OVER 1000 AMPS SQ.IT.FLOOR AREA $/SQ.FT.
NUB Licensed Profeadowl ISIGNSELECTRICAL
M<ZALED - 1 N 1
W
OWNER-BUILDER DECLARATION SPFCLCIiCUIT/MLSC I11,��,/�s,
7s, Ihereby affirm that am exempt from Limited Contractor.Limx law for the - ey1 PUT E
oo pp following reason.(Section 7031.5,Business and Professions Code:Any city or
0Z�q county which requires a permit to construct,alter,Improve,demoBsh,or repai r TEMP.METER OR POLE INST.
g� L❑7 any structure prior to its lswence,a Iso requires the a ppBcant for uch permit to ��/O /'��
L5 file a signed statement that he Is licensed pursuant to the provisions of the POWER DEVICES Y
Q6 3 u, Contractor.1Llceroe Iaw(Chapter9(rommenMg wltF Section 7000)of Dlvl-
n SWIMMING POOL ELECTRIC DAT
ldOp� sion3 oftho Budnnsand exemption. Any
rlation f exempt therefrom and _ VALUA'Ij o
0 the baans for the alleged exemption. Any violation of nal[Section net m by any OUTLETS SWITCHES-FIXTURES 20
GO5p five hundred fees penmtsubjectsthe applicant too civil penalty of net morethan -
R�`
five as dollars
pr/: NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPECONSTRUCTION
7< ❑I,as owner l the property,or my employees with wages r their door
aale ati Zliidoth.workandthestrictureVnotintended or oBemdfor
O saor
M.
7054,Business and Isro(eviore Code:The Contractors License law
does not apply to an owner of property who build.or Improves,thereon,and
a whodoes.uchworkhimselforthr ghhisownemplayeespmvidedthatmeh OCC.GROUP RES,UMTS
improvements are not intended oroffemd forsale.It however,lhebullding or TOTAL:
Improvement lssold withinoneyearofcomplellomtheowner-buBderwill have
thii.4+rden of preving that he did not build or Improve for purpose ofsele.). QTy. „f1t,I 'PLUMBING PERMIT,!',"'-'',IEEE, pl-OOD7DNE APN
"L as owner of the pmperq,am exclusively contntting with licensed PERMIT ISSUANCEcontractors to construct the project(Sec.7054 Business and Professions Code:
The Contractors License law does net apply to an owner of property who ALTER-DRAIN&VENT
builds or Improves thereon,and who contracts -WATER(PA)for such pwjects with a SUMMARY
,,CatI{dm(,)Rmnud pursuant to the Comrmur.License Law. BACK FLOW PROTECT.DEVICE
LII am exempt under Sec B &P C for thin reasonOUTSIDE IT ES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEIPTM
WORKMAN COMPENSATION DECLARATION FD(TVRES PER TRAP SCI;OOL TAX Y_ N_
❑I hereby affirm that I have a certificate of consent to self-Insure,ora RIC ID'P M
ceniftateo(Worker'Compere.aflonlroumnreoram"ifiedwpythemof(Sec.
moo,Lab C.) GAS CA.SYSTEM-I INCA OUTLETS PARK FEE y `N
RECEIPT M
PolicyM GAS EA.SYSTEM-OVER 4(EA)
Com any BUILDING DIVISION FEES
MCediied copy is hereby furnished. GREASE/INDUSTRL WASTEIM'ERCHPTOR PLANCHECK FEE
❑Certified copy Is filed with the city Inspection division,
CERTWICATEOFF EMITION,FROMWORKERS' GREASE TRAP
o
COMPENSATION INSURANCE PAID
(hlsamlnnedn.becompleted lithe permit s(DnSEWERSNITRYST .X .
Date Recei t#
-
(510()orlem.) WATER HEATER W/VENT/7I-ECTR ENERGY FEE Y N
I certify that In the performanesof the work for which this permit is issued,
I shall not employ any person In any manner se an to become subject to the
Woikesa'Compenaatlon laws of CaliforniaATER SYSTEM/TREATINGta. Date PAID
0Z Applicant NEW RESIDENTIAL PCMB. SQ,FT. Dale Rett'[ t#
'Z•O NOTICE TO APPLICANT.If,after making t his Certificate of Exemption,you
should became subject to the Worken'Compensation provisions of the Labor TOTAL:
OC W Code,you mustforthwith comply with such provisions orths permit shall be - - I sas,
j deemed revoked.a BUILDING FEE _
Ljj CONSTRUCTION LENDING AGENCY - SEISMIC FEE
IL Ihereby afthit them Is a construction lending agency for the perform ELECTRIC FEE
M Z ankfor which this permit is issued(Sec.3097
e,of the wor ,CIv.C.) TOTAL:
00 lender.Name - - PLUMBING FEE
LL H Lenaer.Address - QTY: MECHANICAL'"PERMIT', t FEE . MECHANICAL FEE '
OW I cert lfy that l have read this application a nd date that the above Information
a Is correct.I agree to comply with all city and county not leances and state laws PERMIT ISSUANCE FEES PAID:'
N relating to building comtmetion,and hereby authotiae representatives of this
city to enter u pon the above-mentioned pmperty for inspection pu rposes. ALTER OR ADD TO MECH.
? (We)agree to save,Indemnify an d keep harmless the City of Cu peMno DateReceipt#
V against liabilities,Iudgmenes,coats and ex des which may In any way amue AIR 14ANDUNG UNIT(TO 10,"CFM) - • SUBTOTAL:
agar Clty s erre of the this permit AIR HANDLING UNIT(OVER t0,W0 CPM] CONSTRUCTION TAX
.Z f a .CONSTRUCTION TAX PAID:
Signature of pliant onto or Date EXHAUSTHOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO IW,"BTL) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.1Z and the -
Ilealthand Safety Code Section 25537(a)7I IRATING UNIT(OVER 100,000 BTU) TOTAL; It
❑Yen MN.
Will the a pplicarat or future building occupant use eclat pment or devices VENTILATION IAN(SINGLE RESIU) ISSUANCE DATE
which emit hazardous air contaremants as defined by the Bay Area Air -
.�. Quality Management District?' BOILER-COMP(311POR 100,000 BTU) q
No
4h ve readthehazm us materials requirements under Chapter 6.95 of IIOI.ER.COMP(OVER 100,000 BTU) P ~ ID
the California Health&Safety Code,Sections 25505,75533 and 25534.1 nD
understand that if the building does not currently have a tenant,that It 9my NEW RESIDENTIAL MECH. `SQ.FT MAR responsibility to nOify the ompart of the requlmments which nwat be rear 199
prior to issuance of a Certificate of Oaapanry. (�
. .. ISS- v / 1 `cu IIVV
Owner or aulhmiaed agent Date s,
TOTAL: UED BY:
OFFICE COPY