23938 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Pro'ed Identification - PERNI TNO.
Builtqia�ding Addg LA
.^ .1Mw vTJ— 23938
w.rs ante:. R - //7p`/ `
Phone: p p p
` � CITY OF CUPERTINO-BUILDING DIVISION
Contr ante: d'N�\ A� w �.plo: APPLICATION / PERMITG14
a /Y /� $ BUILDINGELECTRKALPLUMBING-MFCHAMCAL CATEGORY CONTROL N
Amhlted/Engine.. LIC.No:
( QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO'-
Addro.: O� PERhRTISSUANCE
LICENSED CONTRACTOR'S DECLARATION �J �r
IMrebyaffirm that l am licensed under prosislons of Chapter9(commenc APPUANCESRESIDEMTAL �, JOB O ram�0� -
ingwithSNUon7000)ofDivIa.3of B essand ProfeulonsCode,and my `'`_;'L^� -'"-.�7x
lice..Is In fir rc and.tied. PANELS
Data C�ss�Lic.x Pw,1 n ��'I Asa_t,(.
Dattel/_a7/N/7 Contactor pt 1�TO ANS ^V Ft c
ARCHITECT• R TI
HIreO Zp
understand my plane shall be used as public records. OVER 1030 AMPS SQ.Fr.FLOOR AREA $/SQ.FT.
lyeLicensed Protessio.l SIGNS ELECTRICAL LED ' A'.
�Q cN. OWNER-BUILDER DECLARATION
N SPECIAL CIRCUIT/MLSC e
Z owing r asonn Sh that 7 exempt fromthe d Professions
License Law for the IIS Ja
following recon.(SMlon 7(315,Business and Professions Code:Any city or
O 1:,u9 TEMP.METER OR POLE INST.
qM anystm mph oritoiU permit sthemprovntforsish,orrepto _
.'�i anyswdure priortoib Lcwance,aLwrequireelheapptimt(orsuch permit to POWER DACES -
E F U Ole a signed statement that he is licensed pursuant to the provisions of the Y 7
Contractors License Law(Chapter 9(comB
mendn with Section7000)of Dwi-
3 !`n . w—
elon3ot . feuv
the Buslnsand ProloCode)or Nat heir exempttherefromand SWIMMING POOL ELECTRIC ^ TVAL671Qy
the basis for the alleged exemption. Any violation of Sectio7031.5 by any OUTLETS-SWITCHES-FIXTURES / `` VV r
appBant for a pemdl subjects the applicant to a civil penalty of net more than
c. O five hundred dollars(SM.
1,as owner of the NEW RESIDENTIAL ELEGTR SQ.Fr. STORIES TYPECONSIRUCTION
7¢ ❑ property,or my employees with wages r their sole
.[m(So.7&1n Busdotheworkfmionandthe structure Rnot ntractintenr oroffered for
❑ isle(Sec.apply
Bu sinessandf propeioru Code:The or imp o,es License Taw
does not apply to an owner of pmperh his o nempor impro provided
eory and
whodeessuchworkhimsei(orthraagh Msownempioyees,provided thalsuch OCC.GROUP RFS.UNITS
Improvements are not Intended oroffered for sale.I(howevogthebuilding or TO
Improvement issold withinoneyearofcompletiory theowner-builderwlll have
t1gj�u rd en of proving that he did not build or improve for purpose of ule.). QTY. - PLUMBING PERMIT FEE FLOODZON'E APN
"L as owner of the property,am exclusively contracting with licens d pERMITIS5UANCE
ontm&om to construct the projed(Sec.7044,Bus and Professions Cade:
The Contractor's License Taw does not apply to an owner of property who ALTER &VENT-WATER(EA)builds or Improves thereon, and who comnim for such ptuj e -
s with a FEE SUMMARY '
on dor(s)licensed pumount to the Contractor's Llmnm Law. BACKFIOWPROTECT.DEVICE
U I am exempt under Sec .B&P C for this mason
DRAINS A,FLOOR ROOF,ARECOND. SANITARY Y - N
Owner Date BBC=N
WORKMANCOMPENSATIONDECLARATIONpp gp$pp-g•TROT' SCHOOL TAX Y N
❑I hereby affirm that I have a cenifucate of consent to selfAnsu e,or a RECEIPTN
vN� certificate of Workers Compe.ationlvurance ora certified copythemof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Mail,Tab C.) RECEIPT-- PdiryN GAS EA.SYSTEM-0VER4(EA)
Com any BUILDING DI VISION FF.T.B
�CertlOed copy is hereby(umished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCI-IEGK FEE ,
❑CeAiOed copy Is filed with the city inspedlon division.
CERTIFICATE OF EXEMPTION FROM WOR KERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER.SANFLARY-STORM EA.200F1'. Date Recei t#
(This section need not be completed if the permit Is farom hundred dollars
(Sl W)orless.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I mnify that in the performaomof the work forwhich this permit is Issued,
I shall not employ any person in any manner so as to become subject to the WpT[R SYSTEM/TREATING
Workers Compensztlonlawsof California. Date PAID
-
Z Z Applicant - NEW RESIDENTIAL PLMB. - SQ=. Date Remi t#
O NOHCETO APPLICANT.R,aper making this Certificate of Exemption,you
should became subject to the Worker'Compensation provisions of the Labor 1 TOTAL.,
CC y Code,you must forthwith comply with such provblons orthb permit shall be BUILDING FEE
deemed mvokM.
W — CONSTRUCTION LENDING AGENCY L.pVTt
SEISMIC FEE L t L
CL F3 Iherebyaffi mthat there is acon,uudion lending agency for the perform ELECTRIC FEE
Sp
Z ance of the work for which this permit uisved(Sec.3097,C1v.C.) -
U O Iandera Name PLUMBING FEE
LL ~ Lender's Addmss QTY. MECHANICAL PERMIT FEH MECHANICAL FEE
OW Icertifythat l have readthlaapphcationand Aatethat theaboveinformation
IL Isrorrect.I agreelocomplywith all dtyand countyordinancesand state laws PERMIT ISSUANCE FEES PAID:
relatingtobulldingronstrurd and hembyauthorizerepresentativesofthis
F N city to enter pon the above-mentioned property for inspection purposes. ALTERORADDTOMECH. -
? (We)a c to save,indemnify an d keep harmless the City of Cupertino Date RfeelPt#
V ` i11Ucs,' d nems,c.taand ex rases which ma In an a accrue AIR HANDLING UMTCI'010,000 CFM)
aR N B a r your SUBTOTAL:
age' i' CityN consequence o(the granting of this permit.
AIR HANDLINGUNR(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Dale EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will thcappBmnt or future building occupm.tore or handle h.Mous HEATING UNIT(TO 100,000 BTU) Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9:17,and the -
Heahh and Safety Cde Section 25532(a)? HEATING UNIT(OVER 100,0M BTU) TOT
❑Yes N No
Will t1w.pplimnt or future building p..t use equipment or devices VINTLLATION FAN(SINGLE RESID) ISSUANCE DATE
which enn t harardous air contaminants as defined by the Bay Area Air
Quality Manam
geent District? BOILER-COMP PHPOR 100,00B BTU)
4Yes II��No
have readthehaaa usmnerialsrequimmenbunder Ghapter6.95of BOILER.COMP(OVER100,0003TU) ✓/N� �O
the California Health&SafetyCode,Sections 75505,5533 and 75534. I V
I understand that lithe building docs not currently have a tenant,that it is my NEW RESIDENTIAL MECi. SQ.Fr.
s
responsibility
uanonot Ceftiimteof o panche gWrementswhich must be met JJr v NAS
prior to issuance ofaCcrtlfiratc of Occupancy.
Owner or authorized agent Date ISSUED BY: ✓
TOTAL:
1
OFFICE COPY