23935 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Be lid Ing Address: 'PRQ 23935
3 W
neve amt one: p AL DATE
"AiZ. CITY OF CUPERTINe
G DIVISION
cmdraq ane`:' fv fL19.Nolq APPLICATIRM T 'O
• [ C0/VSIG 10� ` o / BUfLDINGEL MAIC L CAL CATEGORY C OJw
A itect/Englrieer. 20
LIc.No,. (J
QTY ELE+REPERMIR FEE BUILDING PERMIT INFO
aaama�330SUNNy TOR'VISfA SJ PFRhBTI ;�, -
LICENSED CONTRACTOR'S D[CLARATION 4- ILUG ELECT PLUMB M�H
I hereby affum that l am Bcensed u rider provisions of Chapter 9(comment AP DE L JOB DESCRIPTION
ingwith Section 7000)of Division 3 ofthe Bmi.Sed Pro(esslon.Code,and m
Bb in full form and effect.
Licenses nLIc.N
Date Contractor
ARCHITECT'S DECLARATION 201-I0OOA.MPS
rsIunderstand etypbrsshaBWused aspub6cremrds jj OVER1 NPS SQ.I7.FLOOR AREA S/SQ.FT.
00
,,Z o Licensed Professional SIGN E L
<w OWNER-BUILDER DECLARATION L CUIT/M15C
i.., Ihemby. lrm that l am exempt teem the Contractors License Lawforthe
M: followingma n.(Sectlon7W1.S,Buslnemand PmfesdmsCode:Anycttyor I
OZ�� .ME[7R OR POLE NET.
p� countywhlch requires a permit tomretmct,alter,improve,demotkh,ar repair
g ,,� anystmoom prim to its Issuance,also requlresthe applicant forauch permit to WER DEVICES Q
_r 8�3 O file a signed statement that he is Ilmosed pursuant to the provisions of the /z
Ou, Contractor's License Law(Chapmr9(commencing with Section 7000).fDie I
lits 3 p tin SWIMMING POOL ELECT- -
L,Et <j ,he huxft for
the usiness
Professions Anyvirthat lation fSecion therefrom and UATION
the basis for the alleged exemption. Anyviolationtolacivi of natty o 70315 re any UILETSSWITCHFSFIXTURES
600 appliantfora permit subjMsthe appllcanttoa civil penalty of not more than
m five hundred dollars(5,5010). NEW RFSIDENI7AL ELECTR I
j 2 ❑I,as owner of the property,or my employees with wages as(Mir sole SQ.FT. STORIES TYPE CONSTRUCTION
ompeneatlon,will dothe work and thestmeture Isnot Intended or offered for
nSale(Sec.7004,Business and Professions Code:The Contractors License law
2 does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP RES UNITS
who doessuch work h enex1forthrough his own employees,provided that Such - ,
improvements are not Intended oroffered forsals.If,however,thebullding or
improvement is sold within one yea rof completion,the owner-bullderwlll have
th,e�+rdeno(powngthat he,did not bund or improve for purTxx. f.I,.). QTY. PLUMBINGPERMIT PEE FIADD LANE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7644,Business and Professlow Code: a
The Contractor's License law does not apply to an owner of property who ALTER-DRAIN&VENT WATER(EA)
Wilds or Improves thereon,and who contracts for such ptojects with a FEE SUMMARY
tpetor(s)licensed pursuant to the Contractor'sLicense Law. BACK FLOW pROTECi.DEVICE
_ ❑I am exempt under Sec. B &P C for this mason -
DRAINS.FLOOR, SANITARY Y N
Owner Dae RECEPfa
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y_ N_
❑I hereby affirm that I have a certificate of consent to sel4lnsum,m FIX.[URF_S PER TRAP a RECEIPT X
certifiLte of Workers'Compersatlon Insurance or a certified copy thereof(Sec. GAS FA.SYSITM-1 WC.40IITLEIS PARK FEE Y_ N_
3500.Lab C.) RECEIPT X
Polirya GAS EA.SYSTEM-0VER4(EA)
Com any BUILD WG DI VISI VFF.ES
n �Certlfied copy is hereby furnished. GREASE/WDUSTRL WASTE INTERCEPTOR PLANCI-IE I. -EE Q
❑Certified copy 6 filed with the city inspection division. 4
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAI _
COMPENSATION INSURANCE
(Thlssectionneednat be completed lithe permit iS formw hundred dollars SEWER-SANITARY-STORM E.A.200FT. ate Recei
(5100)or less.) WATER HEATER W/VENC/ELECTR G YFEE
permit I metily that in the performance of the work for which this pedt is asad,
I shall not em y c In manner so o subject to the WATER
Workers tee Bnm am PAID f
O Z pplicant sit N��Dp Lp�g �� Date eCel t#
Z NOTICE TO I ANT:If,after ma Ing camof Eacmption,you
should become subject to the Workes'Compe bra provtslov of the Labor TOTAL:
W Code,you most forthwith comply with such provisions orthb permit shall be BUILDING FEE ^
W > deemed revoked.
CL
CONSTRUCTION LENDING AGENCY SEISMIC FEE OO
Ihereby affirm that there S a construction lending agency for the perform, ELECTRIC FEE
Oance of the work for which this permit ls Issued(Sec.3097,Civ.C.)
Lenders Name PLUMBING FEE
LL 1—. Lender's Address QTY, MECHANICAL PERMIT FEE MECHANICAL FEE-
U Icertifythat]have read thisapplicationand store Nattheabove Information
O L is correct.I agree to comply with all city and county ordinances and state laws PERMUISSUANCE FEES PAID:
} N co
relating to building vtructon,and hereby authorize representatives of this
city to enter u Pon the above-mentioned property for inspection pu rpows. ALTERORADDTOMECH.
Z (We)agree to save,Indemnify an dkeep harmless the City of Cupertino Date RCCCI}lt#
V against llablllif..,judgmens,mase d expenses which me in anyway accrue AIR HANDLING UNIT(TO 10,"CFM) SUBTOTAL:
agairo[sal 1 cons ence�dy[I a Ing of thle it.
'/,Lr c_ Q AIR HANDLINGIMIf(OVER IO,000CFM) CONSTRUCTION TAX
fnWureof Applicant/Contractor ODate IXHAUSTHOOD(W/DUC'D CONSTRUCTION TAX PAID:
HAZARDOUSMATERIA SDISCLOSURE
Will thea applicant or future building ant store or handle hazardous HEATING UNIT(TO IWp00 BTU)
PP 6 occv P Date RCcel t _
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Healthand Safety Cede Section 25532(a)7 HEATING UNIT(OVER 103,"BTU) TOT 7
❑ Yes No
Will the lapplicant or umardusair contaminants as
occupantuseby the Bay Area devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emithazardous airrict? ante as de0ned by the Bay Area Air
Quality Management District? BOR-FA-COMP pFQ'OA 100,IX0 BTU) � p� p '
El Ya No P M
have read the haze case materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BN)
the California Health&SafetyCode,Sealom 25505,25533 and 25534. I AUG 19 1laa9..
understand that if the Wco
building does not mcntly have a tenant,that it is my NEWRESIDENTIALMECH. SQ.Ff � L
responsibility to Sally the occupant of the requiremems which most W mad
priortoL uanmofa Cedi6ateof Occupancy.
Owner or aumonxcd agent Date TCXQ ISSUED BY: VlJsi r 1
OFFICE COPY