23648 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
'fl.ildlria Pr.ect Identification PERMITNO.
2►5_52 R96N�-r Rn. 23648
n one: A A
hl K'IM �EE
255-qO CITY OF CUPERTINO-BUILDING DIVISION
/ ° APPLICATION /PERMIT
\ BULDING-ELECTRICA4PLUMBING-MMIJAMCAI. CATEGORY -
Lie. o CO
ArcMted/Gglroer. ,
/ I �}�"I„ELECTRIC P,ERMIT• , 4” .;PT♦B` -" .1''IBUI�.DING,PERMY TINFO ,
Address:I oW I Sat p�x /L►.tQ �OS PERMATISSUANCE .
LICENSED CONTRACTOR'S DECLARATION
Thereby e(fvm that lam Bcrnaed underprovfdone ofCha)rter9(mmmrnc APPUANCMRFS1DENfIAL
InersaiSection 7000)ofia-mifd de.n3oflhebuslnesaand PmfessionaCode,anis my �o
license is edfullirm f0mn and died. PANELS
License Clam LICM
Date - ContraRor
ARCHITECPS DECLARATION 701-1000 AMPS
Ore O7. IUnderstandm Uro shall be used public records. OVER1000AMPS FT.Iq.00R AREA
pkv YP Po c$ 5/SQ.FT.
FiU E LicensedProfemlonal SIGNS ELECTRICAL
fn]a� OWNERexempt ERDBCLARATION SPECLILCB2CUIT/MISC ADD ` S] a
following reason.ffirrathat
731.5,Bfromthe Com.dsions erse ode:Gov city or J V '
O R t-� (allowing reason.(Sedlon 70(1.5,Businem end Professions Cade:Any city or �x
F county which nNumsa permit tommtmd,alter,improve,demolbh,.rrepair ';'Y"g ' O POLE INST.
a anystvnure prime to its Issuance,also requlreathe applicant forsuch permit to I ' '' ' y r..,
TNG a V file a signed statement that he Le licensed pursuant to the provisions of the I'OWrR DEVICES,
3�G Cont.dor's License Law(Chapters,(mmmencing with Section 70M)of Divi- S NG POOL ELECTRIC r
slon3ofthe Businessand Pmf miomCode)orthathe Leemmpttherefromand VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any
p�
applicant fora permit subjeds the applicant toa civil penalty d not marc than O TszWITCHEs PlxrURESf BP L I
ggg five hundred delta.(S500).
❑I,as owner of the property,or my employees with wages as their sole NEW FICAbSMAL ELECTR SQ.FE S'IDRICS TYI'li CONS'1'ILUC PION'
< comps...don,willciothework.andthestmcture Lena intended or offered for
5 D sale(Sec.7094,Business and Profemmrd Code:The Contractor'.License Law _
�3� does not apply to an owner of property who builds or Improves thereon,and OCC.GR0111' RFS IINTTS
who does such work himself or through his own employees,provided that such
Improvements are not Intended or offered for sale.If,however,the build Ing or TOTAL: s
Improvement issold within oneyearofcompleliomtheowner-buBderwlll have
t burden of pmvingthat he did not bund or Improve for purpose ofsaled. QTY, .PLUMBING PERMIT ''FEE,'' FLOOD ZONE APN
{as owner of the property,am exclusively mntracifng with licensed pFBMIT'ISSUANCE a�q
contractors to contact the Project(Sec.7044,Business and Profemlons Code: f/
The Contradorb License law does mat apply to an owner of propertwydy�ho I A ji� D ,
'builds or Improves thereory and who mounds for such ptokds I t a -
sa
_AV
Cgp([.dor(e)Ilcensed pursuant to the ContrddMe License Law. B - T ` ' 'FEE SUMMARY•'
LJ I am exempt under Sec B fa P C for this reason
Owner Date - ND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RECEET N
i
01 hereby affirm that I have a certificate of consent to sel6lnsure,or _ D O SCHOOL TA% Y N
cedlficate"Workera'po reatlo onmesoracedified mpyshereof AFLFR'1'M
3800,Lab C.) AS.EA.SY -1 INC OUTLETS PARK FEE Y_ N
Policy N - - RECER'f N
GAS EA,SYSTEM-OVER 4(EA) - BUILDING DIVISION FEES
myla "reby he CREASC/INDUSTRL WASTE INTERCEPTOR FL CHECK PEE �� �®
Certified py filed with the dry Inrprction division. G C Q
CERTIPICATEOF EXEMPTION FROM WORKERS' GREASETRAP PAID� V���
COMPENSATION INSURANCE SEWER-SANPfARY-STORM EA.200FT. Da Re0.'1 N
(TATs.Mian needot nbe completed if the permit Le .(aeons hundred colla
($100)orlem.) WATER I IEATER W/VENT/ELECTR ENERGY FEE Y_��
I certify that the performance of the work forwhl b cae this permit is Issued WATER
I shall not employ any person In any manner ao es to bemsubject to the O
Worke.'Compensation lawi of CalifomLe. Date - WATER SYSTEM/TREATING —� PAID Lr
O Z Applicant NEW RESIDENTIAL PLM B.
Z 0 NOUCETOMPLICANT:1{ahermakingthLeCedlffcat.of Exemption,you SQjrE - Date Rewi t#
should be0ms subject to the Worke.'Compensation provisions of the Labor TOTAL:
WN Code,you mus:forthwith comply with such provisions or this permit shall be
> deemed revoked. BUILDING PEE L
11 p CONSTRUCTION LENDING AGENCY SEISMIC FEE
.Ihembyaffirmt .30hat there is a construction lemdingagency forths perform TELE
Z' ance of the workfor which this permit Le Lues (See97,Civ.Q .O
O O Le.der'.Name TOAL CTRIC FEE
- PLUMBING FEE - -OT
LL F - Lender'.Addreaa - Qt7. . r"MECHANICAL. M1 • ''FEE; MECI-IANICAL FEE' r J,
O W I¢difythatlhave r,adthbappllca0onanddatethattheaboveinformation
C mded.l agreeto comply with all dtyand muntyorciiwnaa and orate laws PERMIT ISSUANCE � FEES PAID:
In relating to building constmctlon,and Aereby autholan representatives of this
F Z city to enter upon the above,mentioned property for taped Ion pu rposes, ALTER OR ADD TO MECIL B
Z (We)agree to save,Indemnify an d rmiem the City of Cupertino Date Receipt#
a g.miulI.bJEtIra,JJ menta and pen swhic msyloanyw accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
Q
aga Wtsaid ft CityI o ogr' ng oft perm)
AIR HANDLING UNIT(OVER I0,oDOCEM) CONSTRUCTION TAX
SI rat ppl nt/ tract Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: t
A DOLS ATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UMT(TO 100,000BTU)
mxterialasde0ned by the Cupertino Municipal Code,Chapter 9.12 and the _ Date ReceI of
Health and Safety Code Section 2M32(a)7 - HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes MN.
Wilitheapplinnt or futureWildingocdrpantuseequipreet.,devices VENDLATION FAN(SINGLE RE.SID) ISSUANCE DATE
which emit hazardous air wetadanants as defined by the Bay Area Air
Qu❑silty Mawge,rcnt Dlstrld7 BOILER-CDMP(31'1?OR 100,0(1)6TU)
Y.s No
have read the Nazar alis nutedais requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health k Safdy Code,Sections 25505,75533 and 75534.1 -
understandthatif the building does not mamntly have a tenant,that it Le my NEW RESIDENTIAL MECH. SQFT.
t'.
responsibilityriortt.notifyCeti ompantof the mpancquircmen.which moat be cant PAI' prior to Lumnce o/a Cediticete of Occupanry. � t; - r
Owner or authorizedagent Date ISSIRiDb
TOTAL: -D —
OFFICE COPY Cl Y Ur L y��
_ n nnu