23725 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PER)ATNO.
B°°ding Addmu: 23725
9 o a
A weer. aces: Ra� APPLICA DON SUBMIFIAL
� �J 9904 CITY OFCUPERTINOBUILDINGDIVISION
CootraanrsName: ` I Lk. APPLICATION / PERMIT b
G /✓�JLL� Y�,6�X BUILDINGELECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL N
Archi( /Engineer. - Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
4PERMITISSUANCE - ....-- ®.
LICENSED CONTRACTOR'S DECLARATION X'
I hereby affirm that l am hcensed under provWonsof Chapter9(commenc APPUANCESRESIDENITAL
tagwlth Scd1on7000)udD1vtsIoe3 oftheflusinessand Pro/essiamCDde,and my IAlL�/7�
li.e.e ie In full fo and effect. PANELS
Lkensc Lic.N '
Date Contractor aUP TO 200 AMI�S
ARCHITECT'S DECLARATION 201-I000 AMPS
as
Zp I understand my plats shall be used as public records. OVER 1030 AMPS SQ.FT.FLO}Q}°?AREAO
5/SQ.FT
FL� Licensed Professional SIGNS ELECTRICAL
GG OWNER-BUILDER DECLARATION ` T
1n a SI'CCIAL CIRCUIT/MISC
I herebyalRrm that I am exempt from the Contract./e LI¢nse Law for the
pp O'y fallowing Mason.(5ectlon 70)15, ness Busiand Professions Code:Any city or t:. TEMP.ME7f0t OR POLE INS(.
K4
gc.untywhlch requBeapertNtva
t tocov ,alter,Improve,demolish,orrepair
any.twcture prion. W
its uance,also requlrestheappBES
cent for such permit to POWER DEVICES
5l- file a signed statement that he it;licensed pursuant to the provisions of the
Contractors License Law(Chapter 9(commemingwith Section 7000)ofDivi.30 eW.3.fth.Buslnessand Profemlov Code)orthat heb exempttherefromand SWIrf'bING POOL ELECTRIC VALUA'IAVS
the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCFIFSFIXT[R9E5
applicant(ora permit subjects the applicant to•dull penalty of on rrore thin V
five hundred dollars WEKB. NEW RESIDENTIAL ELECT°
�n ❑I,as owner of the property,or my employees with wages as the4 wk �'FT' STOW ES TYPE CONSTRUCTION
C „compensation,will d o the work and the structure is not intended or o/femi for
S O In(Sec.7044,Business and Profemlov Code:The Contractors Llreve Law
S$ 'dEvs not apply to an owner of property who builds or improve,themreon,and OCGGROIIIa RFS UNITS
who doeuch work himself or through his own employees,provided that such
Improvements are net Intended orolfered forme.If howaveylhebulldingor T
kaprovement bwld Mthinoneyearofcompldion,theowner-bu0derwill have
the_*rdenof pmvingthat he did nnbulldorimprovelarpurposesofsale.). QTY. PLUMBING PERMIT FEE FLCOD ZONE APN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(See 7094,Business and Professions Code:
The Contractor'.License Law don not apply to an owner of property who ALTER-DRAIN Is VENT-WATER(EA)
builds or improves thereon, and who contracts for such ptujecta with a FEE SUMMARY
coSjpadorU)Ilcenecd pursuant to the Contndori Lken.e Law.
Lj I am exempt under Sec B k P C for this Mason BAIX FLOW PROTECT.DEVICE
OUTSI DE FE—ES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner' Date RECEPT M
M
WORK AN COMPENSATION certificate cere -
DECLARATION FIXTURES- TRAP SCHOOL TAX Y N
❑ have
I hereby affirm that 1 have a rtificate o!consent to self-Insure,or �• RECEIPT N
certificate o(Worken'Compensatlanlvurance oracerti(kd ropylhemo!(Sec.
38GAS EA.SYSrEM-11NCAOUTLEfS PARK FEE Y N
Policy N Y CJ RUING
DI N
Co ay GAS sR4(R�s) 0 ECKFNCDIVISIONFEES
enlBed copybhereby fumi.hed. GREASE/I DUSIRLWASTEINTERCFPTOI2 PLANCI-IGCK FEE
Certified copy-is filed with the city Inspection division. _ {.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE C E t� PAIb �''
COMPENSATION INSURANCE SEW.�-SAMTARYSIORM EA 200 Date Recei t#
Rhiewctbn need nn be completed Bthe permit b forans hundred dollars
(Sim)or I.ss.) EN RCY FEE Y N
I certify that in the peffurmanxof the work far which this permit is unread, WA HEA Al _tel
I.hall not employ any Pere..In any manner w an to become wbject to the WATQt SY57EM/TREATING
Workers'Compensation Law,of California.Date PAID
Z Z Applicant NEW RESIDENTIAL PLMB. FT. Date Recei t#
Z O NOTICE TO APPLICANT:If,after making this Certificate.(Exemption,you
Fshould bcmmn subFct tothe Workers'Campensallan provblons.fthe Labor TOTAL:
cc N Code,you moat forthwith comply with such ptovlalov or this permit shall he r
deemed revoked. BUILDING FEE
W
CONSTRUCTION LENDING AGENCY SEISMIC FEE
IhembyalRrmthat the'.is a construction lending agency for the perform ELECTRIC FEE
Z once o(lFe work!or which this permit b issued(Sec.3097,CIv.C.) OT ��
(� 4 7ender'c Na me PLUMBING FEE
LL H Lendee.Addmss QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW 1 amify that!have read thlsappliced ...dA.mthattheabovelnf..tIcn
fl Ucormot.Iagreemcomplywlthall dlyand countymelinancesand stalelaws PFRMITISSUANCE FEES PAID:
>. W relating to building construction,and hereby authorize representatives of this
F Z city to enter upon the abovcmmaiomdl property for Inspection purposes. ALTER OR ADD 3D MECH. Date RI [#
— (We)agree to save,Indemnify an d keep harmeCCP
less the City of Cupertino
agaWtBabNtk:a,jrdgmenG,omtaandexpmse.whkh mayin anywayacerue AIR HANDLING UNIT(17010,000CFM) SUBTOTAL:
a tuM city In sequence o(lhegranting of permit AIR HANDLING UNIT(OVER 10,IDOCFM) CONSTRUCTION TAX
tgnaturc of ApplCont or Olt. EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the ,fined bytheant or urc ruin ngoacipant lCode, hapter9.rhandic ha and the HEATING UMT('IO 100,000 BTU) Date Receipt#
material as defined bythe SCupertino MunicipalCode,Chapter 9.12,and the -
Fkalthand Safety Cadera��Section 75532(.)7 HEATING DMT(OVER lm000 BTU) TOTAL:
r_1 Y. rfu No
Willtheappikant haAardusair cumrulldingareflue use the Ba Area desks VENTILATION PAN(SINGLE RFSID) ISSUANCE DATE
Quality Management District?
by the Bay Arca Air
Quality Management District? 80ILER-COMP OHP OR 1m,IXD BTI. PAID 8
. 4Yes n❑No B' P'i
haveread the bazardou,materials requirements underChapter6.95 of BOILER-COMP(OVER100,000 BTU)
the California Health k Safety Code,Sections 25505,2SS33 and 25534. 1 qy 2� 1992
understand that 11 the building does nor currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT
responsibility to notify the occupant of the requirements which must be met
pr to Issuance ola rtmate.fDttupancy. — GI I Y Ur !aur Cn 1114%
no,m authorlud agent ISSUED BY:
Tf T
OFFICE COPY