23509 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: - t?Lvo r 23509 3 r O 9
cense: one. A G A{J AAA
5tt✓M n1�J �(�[1�• Z57_-7D[) CITY OF CUPERTINO-BUILDING DIVISION
cantmnor'.Name: Lk.No: APPLICATION / PERMIT
s
BUILDING-ELECnUCALPLUMBING-MECHANICAL CATEGORY COfR O
A itm/Fiigtncer.
Lie.No. b
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: AW6as L. PERMITISS(IANCE ❑ 11 El
CONTRACTOR'S DECLARATION
I hereby affirm that l am Bernard under provisions of Chapter 9(commene. APPLIANCESRESIDENTIAL JOB DFSCRIPDON
ingws,I,infon force and effect.
Buslnessand RelesvonsCode,end my F owe l�?S�
Therm Is in full force and dfect. PANQ,S /
LlrenscClam Lk.M
Date Contractor
ARCHITECT'S DECLARATION 201-1WO AMPS
NIctzp
understand my plans shall be used u public records. OVERIOOOAMPS SQ.FT.FLOORAREA $/SQ.Fr.
(/ Licensed PMessWrul SIGNS ELECTRICAL
�6N OWNER-BUILDER DECLARATION SPECIAL C]RCNT/MISC
Z F.�/ Iherebyaflirmthat lam exemptfmmthe Contractor's License Law for the _
Ko Q following mum.(Sectur70315,Businessland Professions Code:Any city or TEMP.METER OR POLE INST.
4M6 county which requlresa permB tocorutruct,alter,improve,demolish,orrepair
`•� 7 anystmu mpr rtoltsL ame,alsorequir theappbuntforsuchpermuto
c. file a signed statement that he la licensed pursuant to the provisions of the POWER DEVICES
Contractor's License BLaw(Chapter9(commencing with Section 7000)ofDwi- SypNAgNGIVOLELE
O s1on3 ofthe usiness and ProfessionsCode orthat he In exempt therefromand VALUATION
the basis for the alleged exemption. Any violation of Stolon 70315 by any
`u�<5 applicant fora permit subjects the applicant to a civil penalty of act morethan OUTLETSSWITCHFSFT%7LRFS site
c. five hundred dollars($500). NEW RESIDENTIAL TR
j.. F-11,as owner of the property,or my employees with wages as their sole `''Q�' STORIES TYPE CONSTRUCTION
t compensation,will dothe work and thestrunure is not intended or offerecifor
.400
5 uk(Sec.7W4,Business and Professions Code:The Contractor's License law
$$ does not apply to sin owner of property who builds or improvm therron,and
w who doessuch work hlmxelforthrough Ms own employees,provided that such OCC.GROUP RES.AMTS
improvements are net intended orolfered for sale.If,however,the W ilding orALo
Improvement a sold within oneyear ofcompletion,the owner-bu Ilderwlll have
t ,dent of proving thathe did not Wild or Improve for purpose of sale.). PLUMBING FEE E7.00D7ANE qPN
4 as owner of the property,am exclusively contracting with licensed —si
contractors to mrutruct the project Seel Business and Professions Code: IT ISSUANCE
prod ( 014
bThe Contractor's imp License law don net apply tct an owner p property who AL -DRAIN A
uilds or Improver thereon, and who contracts for such p(ojeM with a
cgIlS[anor(s)Bcensed pursuant to the Contractor's License Law. FEE SUMMARY
1_f I am exempt under Sec. B&P C for this reuon BACK FLOW O T. C
DRAINS F,A CO SANITARY Y— N—OUTSIDE r
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION I'DOEURES PER TRAP SCHOOLTAX Y_ N
�- ❑1 hereby affirm the I have a certificate of consent to aeB-inwm,ora RECEIPT R
certificate of Workers'CompensatlonInsurance ora certifkd mpythamof(Sec. GAS Ep�,�,� OUTL
3800,Lab C.) PARK FEE Y N
Policy I RECEIPT p
Cony GAS-EA.SYSTEM-OVER 4(
ICBUILDING DI VIS FEES
Certified copy la hereby furnished.
Certified copy bfiled with the city Inspection division. GREASE/INDUSTRLW INTERCEPTOR P]aA��F 'E �\
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP ,/fCp'1 Jv�`.w{ 0
Im
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 20OFT Date ecel t#
(Thlsrem) need nct be complcted If the permit lafororte hundreddollars
($100)curly that
WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
7 cattily then m the person In any runner so an to become
eermit issubjec Issued, —
1 shag not employ any person lo any manner so ns to become subject to the WATER SYSTEM/TREATING
Workern'Compensatlon laws o(Gllfomla.Date PAID
Z NOTlicant
ICE TO APPLICANT.If,after making this Certificate of Excmptlon,you NEW RESIDENTIAL PLMB. SQ}7, Date Recei t#
shwld Wmon subject to the Workers'Compensation powlalons of the Labor TOTAL:
a. W Code,you resat(onhwkhmmplywuhruchpmWiormorthbpermitshallbe
W > deemed revoked. B IL ING FE
t1 p CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirmthat there la a mretruction lending agency for the perform.b
0 ance ofthe work for which this permit tuucd(Sec.3097,Civ.Q TOTAL: ELECTRIC FEE
V Lcadee.Name PLUMBING FEE
IL F Leeder'.Addres QTY. MECHANICAL PERMIT FEE
O W Imnifythmlhavemadthbapplicntlanandmatethatheabovelnfomution MECHANICAL FEE
d incorrect.I agree to comply with all city and county ordinances and state laws PERMI'TLSSUANCE FEES PAID:
} W relating to building construction,and Mrebyauthoroareprcxntativesofthts
j— Z city to enter upon the abova-mentioned property for Inspection purposes. ALTERORADDTOMECH.
— (We)agree to save,indemnify an d keep harm0ess the City of Cupertlno Date Receipt#
against liabilities,Ndgments,costs and expenses which may in any wayaceme AIR HANDLING UNIT(To consequence CFM) SUBTOTAL:
against mid City In consaence of the granting of this permit.
AIR HANDLING UN7r(OVER Ioaoa CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Data EXHAUST HOOD(W/DUCD CONSTRUCTION TAX PAID:
HA7 RDOUS MATERIALS DISCLOSURE
Will the applicant or(uturebuilding occupant store or handle havardous HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date RCCei t#
Health and Safety Coda Section 75532(.)7 HEATING UNIT(OVER IDg000 BTIA
F-1 Yes TOTAL:
No
Willthezppliant orfuturebuilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haeardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP 0HP OR IOO,OXD BTU)
Y. No
have read theh rd❑mot materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health&Safety Code,Sections 25505,75533 and 25534.I
understand that lithe building does not currently have a tenant,that it b my NEW RESIDENTIAL MECH. SQ.FT
responsibility to notify the occupant of the requirements which most be met
prior to issuance of a Certificate of Occupancy.
Owner or authorised agent Date
TOTAL: ISSUED BY:
OFFICE COPY