20232 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address:
9773 41� m42 /D/2 2023
i a11hone. A A
I /F/Gfff CITY OF CUPERTINO-BUILDING DIVISION _ C�
Contrsdora Name: a=p.No: APPLICATION / PERMIT
r s 8Q CATEGORY GD.VIRDL l4-d Y
Architcd/En BUILDINGELECTRICALI'LUMBINGMECHAMCAL `a
glneer: Lk.N.
��� ! //�[ �• QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:lelw /�� ✓/J P//� I PERMITISSUANCE I.�. 11�
PLUMB mt,�'H
TLICENSED CONTRACTOR'S DECLARATION
Iherebyafflrm that l am licensed under provisions of Chapter9(comerenc- APPLIANCESRESIDENTTAL JOB DESCRIPTION
ingwith Section 70M)of Division3ofthe9usinessand ProfesslonsCode,and my
license b in full f and effete. PANELS ,I I�t�O.�
License C,L7ss Co Na 9� _ `' (sV//
Dale_.
Contractor .
,/ I/ ARCHITECTS DECLARATION 201-10W AMPS
rs0 7 I understand my plata shag be used m public records. OVER 1000 AMTS SQ.FT.FLOOR AREA S/SQ.FT.
CO
,d(0 Licensed Pfesionid 'SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION f\, 7� C/l
fn Fefi \IA,LCIXCUIT/MISC ( / G�
I- � [herebyaffirm.. te that exemp[fromtheContractor'sLicense Law for the
'�0..'a following reason(Section 7031.5,Business and Professions Code:Any city or I L
O`L t-µ9 ♦ TEMP.METER OR POLE INST.
repair
r anycougmctum requiresa permit croshin quiet thepmvgder socil ormitto
��� any atmdurcprior foits issuance,lice sed pursuanttothe applicant fmsuchpermltlo'I pOK1 R9EViC6S. n
O file a signed statement that he V limned pursuant to the provislo[L.of the _
Contndors License Taw(Cha er 9(oxmmencin th Section 700CWof Divi- I- 11,
3"0l sion3ofthe Bus esand ProesslosCode)ortha8helsexemptlhere`fromand SWA4hII'GPOOLET,ECIRIC VALUATION
the basis for the alleged exemption. Any violation of Se&idri 7031.5 by any / OUILHTSSWITCHESpIXNRES IL
,&D r.�
f��OGX applicant fora permit wbjeds the applicant to a civil pumity of net more t hon b
five hundred dollars($500). //,,II
om I`c /1 ip NEW.RESIDENTIAL ELECTR SQ.F7. STORK TYPECONSIRUCTION
.- ❑Las owner will
the property,or my employees with wages r there sole ^
role(Sec.7ion,wflidotheav'or155f the im Code is em ofoffered lw -
O sale Ince.apply
to a nose and Pr"efesslors Code:The Contra to License ISw 1I
does uctsuclytoanow'nerofpropertywho Wilds orimpr vesthersori,and '(A1LL 1
e•$^
who doessuch worklilrtseBorthmugh hisownemployees,provuled that such - l7CC.GROl1Ia AIS.UNITS
Improvements arenot intended oroffemd for sale.[(howevlrAs buildnn4 or;� _ TOTAL: Q
Improvement is sold within one yearofcgmpletloq the owner-builder ill h.� '
th,�urden of pervnng that he did not bulld'or Improve for purpoN�eo sale.).f QTY. PLUMBING PERMIT PEE FLOOD ZONE APN
LJ L as owner of the property,aml_excluslvely contracting with Yenned PERMIT ISSUANCE
rontradon to ronsimd the project(Sec 7014,Bslnessand PiofeAlo Code: _
The Contractor's License Law does not apply to an owner of Limp who
builds or Improves thereon, and who contracts for such pepiect with a ALTER-DRAIN&VENT-WATER BIM DII
,,LLLLt{intents)licensed pursuant to the Contndor's License Law. 'FEE SUMMARY
LI I am exempt under Sec. B &P C for this reason BACK FLOW PROTECT.DEVICE
OUTSI DF FEES-
Owner Date DRAINS FLOOR ROOF,AREA COND. SANITARY Y - N_
RECEIPT
WORKMAN COMPENSATION DECLARATION N
❑I hereby affirm that I have a certificate of consent to self-insure,or a -� FIXTURES-PER TRAP O D SCHOOL TAX Y N
_
mdt0ate of Workers Compenwtion Insurance re
or a certified copytheof(Sec. S F.A. ECEIPT M
3800,lab C.) GA .SYS EM-I INCINC4 OUTLET'S PARK FEE Y_ N_
Tolley N RECEIPT N
GAS EA.SYSTEM-OVER 4(EA)
Cam any B[[[LUING DI VISION Fl!CB
Cert ed copy Ls hereby furnished. GRFASE/INOUSIRL WASTE INTERCEPTOR PLANCHECK FEE
ddied mpy Is filed'Mth the city Inspection division. 113,46
3-"O
CERTIFICATE OF EXEMPTION FROM WORKERS' G E7RAP PAID 1
COMPENSATION INSURANCE SEWER-SANTTARY-STORM EA.200FT. Date Rec'el t#
(This section need not be completed If the permit is for one hundred dollars
($10(fiorless.) WATER HEATERW/VENT/ELECTR ENERGY FEE Y_ N_
I certify that In the performance of the work forwhlch this per out is issued, �--r1
I shall not employ any person in any manner ao az to become wbjed to the I WATER SYSTEM/TREATING -'# PAID 2- �_ J 1.
Workers Compensation Taws of any mann Date
O Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Revel f#
Z O NODCETOMPLICANT:R,aRermekingthis Cedifioteof Exemption,you
should become subject to the Workers Compensation provislors of the Labor TOTAL: tz 3
Ln Code,you=at forthwith comply with such provisions orthis permit shall be
LU j deemed revoked. BUILDING FEE - T L.
W F3 CONSTRUCTION LENDING AGQ CY SEISMIC FEE.
I]. IherebyafBrrntlut them isaronstruchon kndingagency forthe performrzguo
ELECTRIC FEE
M Zanceofthework fmwhkhthis permit Istcwed(Sec.3097,Clv.C,) TOTAL:(,) OLender§Name - - PLUMBING FEELL Lenders address QTY. MECHANICAL PERMIT O W Icedifytatlhavereadthbappliotiona.ddatethatlheabovclnformationMECHANICAL FEE
Cis correct l agree to comply with all city and county ordinancesand state laws PERMUISSUANCE FEES PAID:
} relating to building construction,and hereby authoriae representatives of this - - q
H N city to enter upon the above-mentioned property for Inspection purposes. 1 ALTER OR ADD TOM �- 6V
(We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
U against Bablllties,pdgmnts,rostsandexpensea whlchmaynnanywayaccrue AR ANDLINC MT 000 SUBTOTAL,
again said BY In cons ceof egrant gofthispenni
y AIR HANDLING UM ovFR l0000cFM) CONSTRUCTION TAX
Signalurcof Apph1 eat cr Dtle' ' IXHAl15E HOOD(W/DIJC'D att�D CONSTRUCTION TAX PAID:
H OUS MATERIALS DISCLOSURE
Will the appBca t or future building occupant store or handle hassrdous HEATING UNIT(p0100,1100 B71n Date Recti t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
health and Safety Code Section 25532(a)t HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes r]No �y:
Will the applicant or future building occupant use equipment or devices VENUTATION FAN(SINGLE RESID) ISSUFj,P10E DATE �4,
which ends havardous air contaminants as defined by the Bay Area Air 1M'�+A11.y�
Quality Management District? BOILER-COMP QHPOR 100,000 BTU)
� 4haveread the haaar7io so materials reqim
uments undet-Chspter 6.955 of B0,
OILER-COMP 1000 BTU) JUN 06 1990
the Glifornla Health&Safety Code,Sections 25505,5533 and 25534.1
understand that if the building does not currently have a tenant.that It is my NEW RESIDENTIAL MECH. SQ.FT. -
responsibility to notify the occupant of the requirements which most be onet A. of(40„y.�_
prior to issuance of a Certificate of Occupancy. - �] of(408,60
Owner or authorimd agent Date p^7
ISSUED BY�•
�
TOTAL: „/�n
OFFICE COPY