23068 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project dentification PERMIT NO,
Building Add mss: -d//r\_ 2 3 O 6 Q
l 012.3 ��s�CS1-f 5� �(j�`'-�_ U
ners ams: `1 One:
y CITY OF CUPERTINO-BUILDING DIVISION taZ-s` .�
TzmemnTA-17=A
eonacteraN Z: Ge.Nee APPLICATION / PERMIT t
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BUILDINC-ELECTRICALPLUMBINGMECHANICAL CATEGORY CONTR
Archited/Enginee LI.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrcas: nklt� I'FRMITISSUANCE • �A T M ❑
LICENSED CONTRA OR'S DECLARA ON LT'J L�J
I hereby affirm that l am licensed under provisimso(Chapter9(commmc APPL.IANCESRESIDENTIAL I BDESCRIPTION
ingwRh SttBon7000)of Dwislon3oftheguslnessand Profes#onsCode,and my
la In full f and eff /1 PANES
Llmnse Cha Lt.N_56_ r
Date Contractor 20
K CHITECTS DECLARATION O ER1FS SQ.FT.FLOOR AREA $/SQ.FT.
2 I understand my plans shall be used as public records.
OOSIGNS ELFLTRIGL..
m u of au
Licensed Professional _ -
�6ro
OWNER-BUILDER DECLARATION t I
IhercbyafOrmthat l am exempt from the Contractors License Law for the SI'[CIA CU1T/MISC. J
OZ � following reason.(Section 70313,Business and Professions Code:Any city or pM LE INET A
FzQ@ countywhich requires a permit toconstmd,alter,Improve,demolish,orrepair
G� anystructure prior to its Issuance,alsorequirestheapplicant forsuch permit Yc to file a signed statement that he is licensed pursuant to the provisions of the
Ow Contractor's License Law(Chapter 9(commenting with Section 7000)of Divi- SWRAMING POOL ELECTRIC
t- sien3 ofthe Business and ProueselmCode)orthat he Is exem therefromand z— [� VALUATION
t✓ 6 5 the basis for the alleged exemption. Any violation of Seddgy nt7MI.5 by any DUTLETSBW(TCHFSFIXTURES l.� J poo ess—
applicant fora permit subjesthe applicant to a civil penalty of nre
ot mothan
w o five hundred delta.(5500). NEW RESIDENTIAL ELFOTR SQ.FT. SI'ORILS TYPECONSTRUCTION
QQQQQQ 1,as owner of the property,or my employees with wages as their sole
compenaatlon,wlll do the work and thcatmcturc lana Intended or offered for
p .In(See.7044 Business and Professions Code:The Contractors License Law
$g does not apply to an owner of property who builds or impeavesthereon,and OCC.CROUP RIS.UNITS
whodoessuchworkhimalforthrwgh hisown employees,provided that such
improvements arc not Intended oroffered forah.If,however,thebulldinger TOT L.
Improvement issold within oneycarofcompletion,the owner-builderwilthave
tl n�,iurden of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD LONE APN
LJ I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to constructthe project(Sec.7044.Business and Pmfc olons Code:
t 5—
The Contractor's License Law does not apply to an owner of property who
Wilds or Improves thereon,and who contracts for such p,jeds with a ALTER-DRAIN&VENT-WATER(EA)
ctado(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sen B &P C for this reasonOUTSIDE FEES
" DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEIPT N
WORKMANCOMPENSATIONDECLARATION� PER TRAP / SCI{OOLTAK Y N. ❑l h(reby affirm that I have a certificate of consent to alfdnaureor a RECEBT N
cemftc;deofWorkees Compensation lsauranre ora certified expythereof eirt. GAS F.A.SYSTEM-1 INC.401PILETS PARK I•TE Y N
3800,Lab C.) RFGRIPI'N
Policy N GAS EA.SYSIFM-OVER 4(FA)
Com ny BUILDING DIVISIO EES
Certified copy Is hereby hamhhad. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE (��a Ia
❑Cert#fed copy 6 filed with the city Inspection division. V
CERTIFlGTE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANRARY-STORM EA 2f10F-1' Date RC i t#
Cfhiss ionneedndbccampldndifthepermit Isforomhundreddolls.
(5100)ar less.) WATER HEATER W/VENT/ELECTR ENE FEE Y_ _
I mrti(ythat h the performance of the work for which this permit Is Issued,
1 shall not employ any person In any manner so as to become subject to theWATER SYSTEM/TREATINGWorkers'Compensattoo Laws of Calitmnia. Date P
O Z Applicant NEW RESIDENTIAL P[MB. SQ.FT. R 1 t#
Z Q NOTTCETO APPLICANT:If,after making this Certificate of Exemption,you
should become subjed to the Works.'Compensation provisions of the Labor TO AL:
F W Code you must forthwith comply with such provisions or this permit shall BUILDING -71or—
S j deemevoked.
W _ d reCONSTRUCTION LENDING AGENCY SEISMIC FEE
hl O I hemby aff enothat there is a construction lending agency for the perform ELECTRIC FEE
Z arcs of the work for which this permit Is laued(See.3097,Civ.C.) TO A.: l�
U O Mclo,a Name PLUMBING FEE
LL F Lender's Address QTY. MECHANICAL PERMIT FEE MECHAMCALFEE
1uAifythat l have read thhapplicationand elate that thcabove information
O W
iscorrect.I agrecto complywlth all city and countyordinanccsand state laws PERMIT ISSUANCE FEES PAID:
r N relating to building construction,and hembyauthorleampresentativeso(this
H Z city to enter upon the abovaemotioned property for lnspOdlon Purposes. ALTER ORADDTO MECH.
_ Date _Re cipt#
(Wc)agrceLinconsequenot
I�thcg
miea the City of Cupertino AIR HANDLING UNIT RO 10,000 CFM) ITAPAID
L:
V agal hichmayInanywayattmeago to Cl lisle permit.
AIR HANDLING UNIT(OVER]0,000CFM) CONSTRUCTIO
CONSTRUCTIO '
Signature of Applicant/Contractor Data EXHAUST HOOD
HAZARDOUS MATERIALS DISCLOSURE {
Will the applicant or future building ocenpantstore orhandle havrdous HEATING UNIT(TO IW,"BTU) Date #materiala defined bythe Cuprtino Municipal Code,Chapter 9.17,and theHealth and Eatery Code Section 25537(a)7 HEATING UMT(OVER 100,000 BTI)
❑Yes MN.
Will the applicant or future building occupant use equipm,nt or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit har rdous air contaminants as defined by the Bay Area Ab
Quality Management Districts B01LF-R-COMP OFB'OR 100,000 BTU) ILL A B D
4Yes F�No V" P9 N
haveread the F 9usmaterialsrequirementsunderChapter6.95of BORER-COMP(OVER 1W,000 BTU)
/-"
the GlBfSmla Health&Safety Code,Sections 25505,75533 and 75534.1 DEC _ 5 ry
understand that it the building does cm ncurrently have a tenant,that It Is my NEW RESIDENTIAL MECH. SQ.FI. 1Jfl
ropmmibllity,to no(ify the occupant of the rcquimments which must be and /� -1 V�S77
prior to Lssuanre Occupancy.a Certificate of O +pancy. Ci
CI Ur um-tilla,
r( -
Owner or authoeed agent Date ISSUED BI ��
TOTAL:
OFFICE COPY