23793 APPLICANT TO FILL IN INFORMATIONVITHIN RED LIN ES`='USE BALLPOINT PEN ONLY
I Building Protect identification PERMT NO.
Building
23793
wners arse: - - Lonme: cAPPLIGAIIONSUBMIIIALDAiL
'0 CITY OFCUPERTINUUILDI DIVISI N
ca artor'eN L9; APPLICATIO RMIT
�•773�- BUILDINGELECTRICA41NGMECHAM L' CA= CONTROLN
rc}I ct/i£_E!81^cer:_ .• r ,
Lie.No:
QTY ELEC C ERM T FEE BUILD INC PERMIT INFO
Address: � _ ( f PERMITISSUAN 15
El ❑.
LICENSED CONTRACTOR'S DECLARATION .
Ihereby affirm that l am licensed under pmvBIonsofChaptCr9(Comment, APPLIAN&S-R&DENTIAn OB DESCRIPTION
Ingwlth5ectian70110)of Divlslon3oflhe Buslneuand ProfesslansCodq and my - 1
Iicenm is in tali(o nd ef(M. P
LI in LIc.N .///JIT (uVl "71�/l
Dae YOB— Contractors 1,
ARCHITECTS DECLARATION201'1000AMPS 1111
ce Zp I understand my plans shaft be used u public record VER SQ Fr.FLOOR AREA S/SQ.Fi.
Oyu Licensed Professional SIGN CAL
y OWNER-BUILDER DECLARATION SPEC L CULT/M I A
piA? Ihereb alRrtn that l am exempt from the Contmones License i�w(or the 'V
ZO Z
County
which oquinsi ion real S,Buslnev and Pimpro s,, Code:Mmeep jr TEMP. ORPLILE INST. p p s...
.P F' mu sty which regrto to perMtloConstmct,als the applicant
such
_ ,� BVO BLS
'� any structure prior to its(swance,aLao requlrne theappBant(ursuch permit to POWER DEVI S" e
yd file a signed statement that M is licensed pursuant to the provisions of the ' _
3u' Contractor's License law(Chapter 9(...c q;with Section 7000)of DIN- ATE VALUATION
sIon3ollholu,in ,s dPa("ss "Cole)o,lhathelsemmpttherc(romand SWIMMI POOL ELECTRIC O
6 the bash for the alleged ezemplion. Any violation of Section 70)15 by any O O TSSWITCHESH)(TURES 2 �O Cy
appbmnt for a permit aub)ects the applicant to a civil penally of not more than v O
live hundred dollars(SSM. -
❑I,asownerolthc property, RESIDENTIAL ELECTR SQFT. STOWS. TYPECONSIRUCTION
p perry,or Rry employees with wages as(heir sole
7a Compenuffon,willdothe work andthestructurc is not Intended or offered for
O saIn csoc.7044,BWisssa.d Profession,Code:The Ccunnu e.Llceve Lw
` e$$, does not apply to an owner of property who builds or improves thereon,and - OCGGROIIP RES.UNITS
whodoe.suchwork himmllorthrough hlsawnemploycns,provided that each
improvements are not Intended oroflered forsale.If,however,thebulldingor -
improvement Band withlnoneyearofcompleBogtMe er-builderwlll have -
t11,Jy�'den of proving that he did not build or improve for purpose of"In.). QTY, PLUMBING PERMIT FEE. FLOODZONE APN
as owner of the property,am ezcluslvcly Contracting with licensed PERMIT ISSUANCE ,
mouton;to conslmct the pmj d(Sec.7044,Business and Professions Code: '
The Comment's License Law does not apply to an owner of property who
builds or Improve.thereon, and,wh.Contracts for such p(oje with a ALTER-DRAIN&VENT-WATER(EA) - t
cgp{jpetor(�Boomed pursuant to the Contractor',License Law. FEE SUMMARY
IL am exempt under Sec. B&P C for this meson BACK FLAW PROTECT.DEVICE
Owner DRAINS FLOOR ROOF,AREA,CONEE SANITARY .Y_ N_
. Date _ RECEIPT
NN
WORKMANCOMPENSATIONDIiC"RATION FIXTURES.PER TRAP SCI{OOLTA% Y N
❑L hereby affirm that I have•Certificate of consent to sAbineare,ora RECEIPT N
cemfivle of Worken'Compensallanlnsunnce ora certllied ropy thereof(gee. GAS EA.SYSTEM-1 AICA OUTL PARK FEE Y N
polis lab C.)
Pollry k HECEGAS P.A.SYSTEM-OVER 4 DING DI M
-�— Cam any BUILDING DI VISION FF.ES
�Cedifled copy 6 herebydwithhecitfurnished. GREASE/INDUSML WA INTERCEPTOR PLANCHECIC FEE
'❑Corti(led copy b(fled with the city inspection division. w�
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID_J� b M
COMPENSATION INSURANCE SEWER SANTE STORM EA 200hT DRIC RCCCI t�
(This sookm need not be completed if the permit b foronehundred dollars
(S]°°)nrfy that
WATER W;�VENT/ELECTR ENERGY FEE Y N
Imrtifythat in o
the perlorsunceafthewk(orwhich this s permitlasuetl, —
1 shall not employ any person in any manner so ast Ve I W bject to the WAT02 TREATING
Workere Coatla a1 GII(omla.Date —�O%` / PAID
0 Z Applies°° Date Recei tN
Z O NOTICETO APPLICANT:If,after ry ng IhExCert o—.fRc.mPtion,you NEW DENTIALPLMB. SQ.FT.
Fsheuldbecomesubpdtethe Worken'Comperuatlon provisions ofths Labor TOTAL:
d2 Code,yaurrwstfarthwithmmplyw11hsuch provlslonsorthla perMbhall be - BUILDINGr e oU
deemed revoked. -
LU
G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby alRrmthat there isa construcla Wtion iendingageneyfor the perform- ELECTRIC FEE
DZ anceof the work(or which this permit ued(Sec,304/,Civ.C.) . ' TOTAL
•U O I.ender'e Name PLUMBING FEE
U. 1- Lcoders Address QTY, MECHANICAL PERMIT ,FEE MECHANICAL FEE
O W I mrtlfylhatl have read thlaapplloationasd tlatethatthe above lnlorma0on
ett.l agree to comply with all city and County ordinances and este laws PERMITISSUANCE' FEES PAID:
d relacunlatingtobullding Construction,and herebyaulhortee repreacmativuo!this
r N city to enterupon the abovementloned property for Wpetllon purposes. ALTER OR ADDTO MECH.
Z (We)agree to save,Indemnify an it keep harrol m the City of Cupertino Date Reeei tp
V against liabilities,judgments,costaandezpenneswhich may lnanywayacave AIR HANDLING UNIT(TO I0,0)0CFM) SUBTOTAL'
against said Chy In consryuenm of the granting of this permit. '
AIR HANDLING UNIT(OVER Ig000CFM) CONSTRUCTION TAX
Signature of AppOvnt/Contractor. Date E%HAUS'T HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willtheapplicant or future building occupartmom or handle haxmous HEATING UNIT(TO100,0DOBTU)
materialasde0ned by the Cupertino Municipal Cod,Chapter 9.12,andthe. ate Recei t(1
H,.Ithand Safety Code 1 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TO A
❑Yea o
Willtheappllcanlor Nre building occupant use equipment or devicesVENTILATION FAN(SINGLE RFSID) ISSUANJ EDATE
whkh emit
aajgcodous air rontaminanb es defined by the Bay Area Nr r pp
Quality Mavgao1o4DlaWtl BOILER-COMP Olfl'OR]OO,IXp BTU) le P's
4 Ye, �gg2
have read the Faza ousmaterialsmquim. enteunderChapler6,95of 3011.1:11-COMP(OVER 100,000 BTU) p
the California Health&SaICy Codf e,Sections 25505,25533and 25534, 1 �•'�.. al
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.hT.1 v ifi�J
__...+,rspotubdity to notify the occupant of the requirements which must be met .
prior to Lmua nee of a Cecilllcate of Onvpancy.
Owner or authorized agent Date - ISgD1.. 1/1
' . 'TOTAL: otiI-If
,. OFFICE COPY