23890 APPLIGAN I IU FILL IN INFUKMAI IUN WI I MIN KtU LINtS — UJt IJALL PUIN 1 FI=N UNLY
Building Project Identification PERMIT NO.
Building Address: 23890
lcqe-13 &del
Phone: APP11CAIION SU13MITTALA
7
S�h4c,f4el_�; CITY OF CUPERTINO-BUILDING DIVISION r
Conor' ame: %' / Lic.No: APPLICATION /PERMIT
7 BUILDING-ELFiCTRICALPLUMBING-MECHANICAL CATEGORYCONTROL#
Architect/ gineer. Lic.No:
QTY ELECTRIC PERMIT FES - BUILDING PERMIT INFO
Address: PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(comment APPUANCESRESIDENTIAL JOB DESCRIPTION
ing with Section 7000)of Division 3 of the Business and ProfessionsCode,and my
license is in fu effect. PANELS
License ss Lic# ;
Date 7a ontractor 7 [/ t
ARCHITECTS DECLARATION 201-1000 AMPS
O I understand my plans shall be used as public records. OVER 1000 AMPS S9.FT. � AREA A /SQ.FT.
F-�!�j Licensed Professional SIGNS ELECTRICAL I IP—��
<cW, OWNER-BUILDER DECLARATION
n SPECIAL CIRCUIT/MISC
L zn I hereby affirm that I am exempt from the Contractor's License Law for the
0-- following reason.(Section 7031.5,Business and Professions Code:Any city or
Z NP county which Y
requires a permit to construct,alter,improve,demolish,or repair TEMP.METER OR POLE INST.
O� Qany structure prior to its issuance,also requiresthe applicant for such permit to POWER DEVICES DATE
o.V file a signed statement that he is licensed pursuant to the provisions of the
3 u Contractors License Law(Chapter 9(commencing with Section 7000)of Divi-
,ion 3 of the Business and Professions Code)orthat he is exempt therefromand SWIMMING POOL ELECTRIC VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCFIESFIXTURFS 1
applicant fora permit subjects the applicant to a civil penalty of not morethan `
m five hundred dollars($500). NEW RESIDENTIAL ELECT R SQ.FI'.
'j ❑I,as owner of the property,or my employees with wages as their sole STORIES TYPE CONSTRUCTION
Z< compensation,will dothe work,and the structure is not intended or offered for
n sale(Sec 7044,Business and Professions Code:The Contractor's License Law
$ does not apply to an owner of property who builds or improves thereon,and
who does such work himself orthrough his own employees,provided that such OCC.GROUP RES.UNITS
improvements are not intended or offered for sale.If,however,the building or TOTAL:
improvement is sold within one yearof completion,the owner-builderwill have
thL�urden of proving that he did not build or improve for purpose of sale.). 4'M PLUMBING PERMIT FEE
u FLOOD ZONE APN
I as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to constrict the project(Sec.7044,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who AI TFR DRAIN&VENT WATER(EN
builds or improves thereon,and who contracts for such pTiects with a - FEE SUMMARY
contractor(s)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
El am exempt under Sec. B&P C for this reason
OUTSIDE FEES
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RECEIPT#
FIXTURES PER TRAP SCHOOL TAX Y N
❑I hereby affirm that I have a certificate of consent to self-insure,ora RECEIPT#
certificate of Workers'Compensation Insurance or a certified copy thereof(Sec. GAS FA.SYSTEM-1 INCA OUTLETS PARK FEE Y_ N_
Polic Lab ) _ RECELPT'#
Polity#_ III t GAS FA.SYSTEM-OVER 4(EA)
Com any 1_' ra iC..�. ,. BUILDING DIVISION FEES
❑pCertified copy is hereby'fuumis ed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�9ed copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Recei t#
(this section need not be completed lithe permit is for one hundred dollars
($100)or less.) WATER HEATER W/VENT/ELF-CTR ENERGY FEE Y N
I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID
Z ApplicantNEW RESIDENTIAL PI MB. SQ Ff. Date Recei t#
O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
C0 Code,you must forthwith comply with such provisions or this permit shall be BUILDING FEE d
V > deemed revoked.
L CONSTRUCTION LENDING AGENCY SEISMIC FEE t
I hereby affirm that there is a construction lending agency for the perform- ELECTRIC FEE
Z ance of the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL:
O Lender's Name PLUMBING FEE
L I= Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
' W I certify that I have read this application and state thatthe above information
is correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID
(L relating to building construction,and hereby authorize representatives of this Z t,
Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. Date R2C21pt#
— (We)a to save,indemnify an d keep harmless the City of Cupertino
against Iia ties,judgments,costsand expenses which may in anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against sa#f City in con ue of the gra�g of this permit.
/ AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
9CONSTRUCTION TAX PAID:
Signature of Applicant/C ntractor Da I7CHAUSTHOOp(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the y
Health and Safety Code Sectio 32(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: J• {/
F-1YesLiss
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSLTA*(f I)ATE
which emit hazardous air contaminants as defined by the Bay Area Air Ir+ /� �✓
Quality Management District? BOILER-COMP(3HP OR 100,000 BTU)
❑Yes o A Q'
I have read the haza ous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) U� a$ 1992
the California Health&Safety Code,Sections 25505,25533 and 25534.I
understan hat if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FI.
responsib'tty to notify he occupant of the requirements which must be met C{{Y Ur. V UJ't n 11140
prior, to uance of a At a of Occup
Z e �_
Owner or authorized agentf Dite ISSUED BY:
TOTAL: 11 y
OFFICE COPY