23274 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building 23274
wnem a 9 one. A A A
�S'T� rqS7_ajq 3 CITY OFCUPERTINO-BUILDING DIVISION
Go=Name: r U_ No: APPLICATION I PERMIT
Arc tee/ BUILDING-ELECTRICALPLUMBING-MECH LAICAL CATEGORY CONTROL N
ghee Lic.No:
QTc' ELECFRICPERMIT FEE BUILDING PERMITINFO
Address: ❑ PLUMB❑
PERMTFISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby aflimnthat lam licensed under provisions o(Chapter 9(commenc- '' APPUANCESRESIDEh'77AL T JOB DESCRIPTION
'ngwfth Scc on7000)of Divlslon3 ofthe Businessa9ProfessionaCcde,andri
license is In fu n P
no; ANELS
License Cla Lk.p J
Date Contnctm 201 1000 AMPS
ARCHITECP DE ATI F
N7 I understand my plain sha0 W used m public records. OVER 1000 AMPS SQ.Fr.FLOOR AREA $/SQ.Fr.
WeOe
Ltj Licensed Professional - SIGNS ELECTRICAL
�<W OWNER-BUILDER DECLARATION
�n Fn SPECIALCBiCUIT/M15C
owing reason.
(that on 7031exempt from the Contractor's License Law for the
QQ following reason.(Section 76715,Business and Professions Code:Any or
FZh't�i mantywhichrequbmapermltt.co.truct,alter,Improve,demolBlioreepair ' T�'tP'ME[ER OR TOLE[NST.
�,,��.c anystructure prlorto its issuance,also requires the applicant forsuch permit to POWERDEVICES
0 file a signed statement that he Is licensed pursuant to the provisions of the
Ow Contractors License Law(Chapter 9(commencing with Section 7000)of Divi- `
30� SWIMMING POOL ELECTRIC
sion3oftheBuslnenandPmfemlomCoae)orthatheice m thcmfromand VALUATION
5 C Q S the bash for the alleged exemption. Any Violation of Sectio76715 by any OUTLETS—SWITCHES-FIXTURES
fora porndt subjects the applicant toa dvil penaltyof act marethan
five hundred dollars(SM. NEWRESIDFAMALELECTR
?� ni,asownerolthe property, my employees with wages as their sole �' STORIES TYPECONSTRUCTON'
c
Oompensation,avilldo the work andthe structure Is not intended or offered for
sale(Sec.7064,Business and Professions Code:The Contractors License Law
3 does not apply to an owner of property who Wilds or improves thereon,and OCC.GROUP RFS.UNITS
who does such work himself or through his own employces,provided that such
impmvemenls are nm intended oroffered for mle.l(howeveq thebullding or TOTAL:
bnprovement Vsold withinoneyearofcompletbo,theowner-builderwlll have
th 4arden of proving that he did not build or improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE FIAODMNE APN
LI L as owner of the property,am exclusively contracting with licensed
contractors to construct the project(Sec.70K Business and Professions Code: PERMIT ISSUANCE
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
Wilds or Improve thereon,and who contracts for such peajects with a
-7n4atot(s)licensed pursuant to the Contractor's License Law. -� FEE SUMMARY
LJ 1 am exempt under Sec. B k P C for this reason BACK FLO PR E r. t
115
DRAINS FUND TFAREA�C D. A TARY Y N
Owner Date RECEIPT p
WORKMAN COMPENSATION DECLARATION . V LTAX Y_ N_
hereby affirm that I have a certlBnte of consent mself-Insure,ora RE FIFT a
certifiate ofWorkeriC mpewtlonlmuranawaarti(kit copythereo!(Sm. GAS EA. STEM-1 EI5 ns
3800,lois C.)r- a•�i1 iD7G/1� L / PARK FEE Y_ N_
I'mliryp RF-CEIPNp
ComGAS EA. 6VERi(FA) — BUILDING DIVISION FEES
�Certiae
g2j]aflfled ropy is filed with tea.0 GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
t he city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE gEWFA-SAMTARY STORM EA 700Fr. Date Recei t#
(This section need not W completed Jthe permit V forone hundred dollars
($100)or to..) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certify that In the perf..rm 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/.I.RG.I.ING'
Workers Compensation Laws of California.Date PAID
O Z Applicant NEWRESIDENTIALPLMB. SQFT. Date Recti t#
Z O NOIICETO N'PLICA,IT;If,after making this Certificate of Exemptlon,you
should become subject to the Workeri Compensation provisions ofthe Labor TOTAL:
N Code,you=at forthwith comply with such provlsioomthix permltshall be BUILDING FEE
deemed revoked.
CL CONthatSTRUCTION b.ONLENDING AGENCY SEISMIC FEE f
CL Iheree work forwhich this permit
lendingagency 097,Cilortbe perform TOTAL: ELECTRIC FEE
7 Z ane,ofthe Nwork(car which this permit uLasuM(See.3097,C1v.C.)
LL O I<naers Adele PLUMBING FEE
LL Q Lenders Address QTY. MECHANICAL PERMIT FEE
O w Ina t.Iagreetoc madthisappmplywithalicitianand dcountyordinances and
MECHANICAL FEE
IL is lagreeto comply with all authorize ordinancessand statelawsPERMIT ISSUANCE FEES PAID:
} W relating to building construction,and hereby authorize representatives o(this
W city%eag;ree
pon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH. Date Reeef t#
to save,IndemNfy an d keep harmless the City of Cupertino Pa ies,' dgments,- nexpense chmayinanywayaceree . AUtHANDLINGUNITQOIO,000CFM) SUBTOTAL:
ity c ( egranf g his permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX
grature of Applicant/ ontnctor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCCCI t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Healthand Safety Cede 37(a)? HEATING UNIT(OVER 100,000 BTI) TOT 71
❑Yes o
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havardom airronta ants..defined by the Bay Area Air
QualityM.mgcment Distrl BOILER-COMP(3HI'OR 100,000 BTU)
Ym o
have read the hazardous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health 6 Safety Code,Sections 75505,25533 and 7:534.I
gan
d that lithe building does not corninly have a tenant,that it b my NEW RESIDENTIAL MECH. SQ.FT. P I D
el
ibility tonotify theampant of the Irementswhich mustW met issue of a Certilkat ! cevpa
_ SEP — R +
Mori .gem Date
ner ora TOTAL ISSUED BY:
OFFICE COPY