23466 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Passed Identification PERMIT NO.
Building Address: n 23466
20 t-},oc) 1�N t RJ•�
nersName: one: ATr
S 3(9- —371 CITY OF CUPERTINO-BUILDING DIVISION � 8 Q2_
co vada .Zry APPLICATIO I RMIT l
`C BUILDINGELEC-iWCAL BINGMECHAMCAL CAT[GORY C
W Architect y�a s LIC No:
p-1l y.Qr mAVjQv- GO 57 1 QTY ELECT CPERMIT FEE BUILDING PERMIT INFO
Address PERMIT ISSN ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I berebyafflrmthal lamlicensed under pro,blonsofChapter9(commenc APPLI C
f rce and dfect
.
, RFSIDEN r� JOB�DES�C OTON
ugwft Socon7000)o/Dlvsonysl d onaCadeand my cemse 1s full
Llmnse G
Date Contractor
ARCHITECTS `
{
DECLARATION d000 AM
Q'Z I understand my plans shall be used as public records. J OVER1 FLjjT $/SQ.FT.
t BVV
COC
I�U Licensed Professional A CAL — ER
NR��
Q. OWNER-BUILDER DECLARATION SP IA CULT/MISC I f 1 Y E 1 `
L., p I herebyaffirenlhat l am exemptfrem the Cantraclore License law foe the
K O�W following reason.(Section 7MLS,Business and Professions Code:Any city or ETFROR POLE INST.
Z
ul muntywhich requires a permit tororetrud,alter,improve,dennlbh,orrepair
S �.a anystructure pdorlo lis issuance,also mqulrestheappllcant for such permit to POWER DEVICES
Vfile a signed statement that he Is licensed pursuant to the provedons of the
8s 1
Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SW'AIMING POOL ELECTRIC VALUATION O sion3ofthe Busmessami Pmfessions Codc)orthat he 6 exemptm
therefroand c
< the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWTfCHESHXTURES
appU.et tura permit subjects the applicant to a civil penalty of not more than
n five hundred dollars(SSM. NEW RESIDENTIAL ELECTR FT.
I,as owner of the property, SQ STORIES TYPECONSTRUCTION'
p perry,or my employees with wages r their dole
�7¢ compensationwilldo the,Business and Ikandthedrude:TheCm,is not intendedo License
ed for
Law
O sale(Sec.7016,Business and Iarofesslans Code The Contractors License Law
Q3� does not apply to an owner of property who builds or improves therron,and OCGGROUP RFS.UNITS
who does such work himself or through his own employees,provided that such
improvements arc not Intended or offered for sale.If,however,the build Ing or TOTAL:
improvement6saldwlthlnoneyearofcomple iogtheowner-builderwill have
`• %�r nofprovmgthat he did not bunD
d or improve for purpose ofsoleI QTY. PLUMBING PERMIT FEE FLODZONE APN
L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(See.7014 Business and Professions Code:
The Contractor.License Law does not apply to an owner of property who
Wilds or Improves thereon,and who contracts for such p�ojeds with a ALTER-DRAIN&VENT-WATER(EA)
cgl1S[actor(s)licensed pursuant to the Contradoes License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LII am exempt under Sec. B&P C for this reason
DRAINS FLOORROOF,AREA,COND. SANITARY Y_ N_
Owner Data RECEIPT N
WOR KMAN COMPENSATION DECLARATION pp(NRES PER TRAP SCHOOL TAX Y_ N_
F1 hereby affirm,that 1 have a certlllcate of consent to self-Inmrre,ora RECE3?r N
cerifrate ofWorkeri Compensation Insurance ora certl(led copy thercoftSm. GAS EA.SYSTFM-1 INCAOUTLEIS PARKFFP Y N
3800,lab C.)
Policy N RECEIPT M
Com CAS EA.SYSTEM-0VER4(EA) BUILDING DIVi510 EGES
mc-zified copy 6 hereby furntshed. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy 6 filed with the city inspection division. O
I J
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID _
COMPENSATION INSURANCE SEWER-SANRARY-STORM EA XpFI• Date ecei t#
RMssedionneedrot Wcomplded Iftheper t6futurehundreddollars
(5100)or Iem.I E EE Y_ N_
I certify that In the perf.renamr.fthe work foewhleh this permit 66sued, WATER HFATQt W/VENT/ELCLT1t '
I shall not employ any person In any manner so as to become vabjed to the WATER SYSTEM/TREATING O
Workers'Compensation laws of California.Date PAD ,_L b—
O Z Applicant NEW RESIDENTIAL PCMB. SQ.FT. to Recei t#
Z O NOTICETO APPLICANT.If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor BUILDING�� TOTA .:
CCN Code,you must forthwith comply with such provisions or thin permit shall be
W J deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL F3 it ID
Ihcrebyaffirm that them is a coruvuction lendingagency loathe perform T ELECTRIC FEE
Z anceofthe work forwhichth6 permit 6issued(Sec.3097,CN.C.)
(� O Lender's Na 'PLUMBING FEE
me
LL H lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL •'E
OW Icerilythat l have read thin application and state thatthe above Information
M 6correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. relatingt.b.ilding..t.di.n,andhercbyauthorizerepresentativcsofthis
H In Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH. Date ReCCIPt#
(We)agree to save,Indemnify an d keep baroness the City of Cupertino
V against liabilities,judgmen6,costsand eapunsm which may In any wayacceue AIR HM,IDLING UNIT(TO 10,000 CFM) S TOTAL:
ago sal City In cone renceofthe gmetingofth6p It.
3�if q AIR HANDLING UNI (OVER 10,000 CFM) CONSTRUCTION AX
Si store of Appllcem/Contractor Dae EXHAUST HOOD(W/DUCT) CONSTRUCTION XPAID:
HAZARDOUS MATERIALS DISCLOSURE
Willthe applicant or Whim building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date R Cel t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
[Ieatth and Safety Code Section 25532(a)7 HEATING UNIT(OVER]00,1100 BTU) 'I'
❑Yes
Li No
Will the applicant or Wturc building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management D6Wct7 BOILER-COMP OHPOR 100,000 BTU) q
•
I❑PIY.:s m �I�II No BOMER-COMP 100,000 BTU)
I have ad the haus mte
aria6 requirements under Chapter 6.93 0(
the California Health&Safety Code,Sections 25505.25S33 and 25534.1
understand that lithe building does not cormntly have a tenant,that it Ismy NEW RESIDENTIAL MECH. SQ.FT OCT
responsibility to notify the occupant of the requirementsmost which W met 15 y(]Qey
prior to issuance of a Certificate of Occupa my. L7�7I
Ownerorauthorie agent Date ISSUED BY:TI 1 `aUY1
TOTAL:
OFFICE COPY