23415 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PFRMUENO.
Building Address:
23415
nen onto one: A A A
� i Les i i It-, X0.5 -gq CITY OF CUPERTINO-BUILDINCDIVISION
G°nt" ors""n°' LIC Na APPLICATION / PERMIT
J �5 Maso r035 BUILDINGS.ECTRICAL-PLUMBING-MECHANICAL CATEGORY CONTROLN
AmAlt¢ct/Engineem Lic.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add.
PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l an,licensed under provisions of Chapter 9(ecommosse. APPLIANCESRE51DENTAL JOB DFSCRIIsTTON
ingwlth Se tion7000)of Division 3 ofthe Businnsand PmfessionsCode,and my
license is in fuLLfor�oe deffect. y� PANELS
License Clam ,2Lq LIc.N 359
Date CHITECr_ ry /
ARCHITECTS DECLARATION OVER0O AMPS
ODOAM r
[e0ZOC Iundcrstand my plaresluBbe used upublicrcmrd a. OVER 1000 AMT'S — OOR EA
cFx1'(� Licensed Profembnal SIGNS ELECTRICAL
�<<6� OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MLSC
7 H r<3 I herebyafRrrnt0 I am exempt lromthe Contractor's License Lw(orthe
following reason.(Section 7MI.5,Business and Professions Code:Any city Or
rF'c� cmntywhichrequlresapermRtowmtmd,atter, pmve,demolbhorrepair TFMP.MErERORPOLEINST
any structure prior to its Luna nee,also requires the applicant for such permit to
g a file a signed statement that he Is licensed pursuant to the provisions of the POWER DEVICES
Contractor's License Law(Chapter 9(commencing with Section 70M)of Divi-
slon3ofthe Busine dPmfenioruCode)orthathebemmpttherefmmand SWIMMING POOL ELECTRIC VALUATION
yd the basis for the alleged exempUen. Any violation of Section 70315 by any
'u'1< appLLant fora perndtsubjectxtheappllcanttoa civil penaltyanot moretlun OUMETSSWITCHES-FIXTURES
o. five hundred dollare(S50O.
7�n n I,as owner of the property,or my employees with wages as then sole NEW RESIDENTIAL ELECTR SQFr. STORIES TTIE CONMUCT10N
� Q c penation,wllldothework,andthestmM.brwtintendedorofferedfor
$ D sale(Sec.7094,Business and Profeulov Code:The Contractors Lim.Law
$$ does net apply to an owner of property who builds or Improves thereon,and
who doessuchwork hlmselforthmugh hiaownemployces,provideelthat such OCG GROUT' RES.UNITS
Improvementsare not intended oroffered forsale.'I(hmvevegthebuilding or TOTAL:
impmvementbs dwithinoneyearOfcomplmion,theowner-WederMllhave
t Men of proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEEpLOODZANE ApN
L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to consW ct the project(See.7099,Business and Professions Code:
The Contractor's License Law does net apply to an Owner of property who
Wilds or Improves thereon,and who contracts for such ptOjects with a ALTER-DRAIN&VENT.WATER(EA)
cgBt ee etor(s)licersed pursuant to the Contractor's License Law. BACK FLAW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under SB k P C for this reason
QUISIDE FEES
Owner Date DRAINS FLOOR,ROOF,AREA,COND. SANTEARY
WORKMAN COMPENSATION DECLARATION RFLQm'N
01 hereby affirm that I have•certificate of consent to self-insure,or a FIXTURES PER TRAPSC{OOL TAX Y N
certificate of Wcrkers'Compeoxatloa Imuran Ora ramified copy themof(See. RECEIPT N
380,Lab C.) �" '/ GAS PA.SYSTEM-1 INCA OUTLETS PARK FEE Y
Policy# ziggin, _ N_
_� RECEB'rN
Cam S F.A.
Pany_/'t , L �.�/� 1' G� GASYSTEM-0OVER BUILDING DI VISIONFEES
❑CemIR op bherebyfumisFied. _
Q2e'nified copy b Bled with the city inspection division. GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(rhbxectionnced not becmmpleted lithe pemut bforone hundred dollars SEWER.SANITARY-STORM EA.200FT, Date Reeel til
($1 I0)orle th) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I mnot thatinthe penuunceofthework so aswhich tobthispermitblasted,
I shall not employ any person In any manner at u to become subject to the —
WorkerdCompensatlonlawsofCalifornb. Date WATER SYSTEM/TREATING
O Z npApplicantPAID
Z O NOTICETO APPLICAM;If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB._SQ}7, Date ReCei til
Fshouldt, m—subjM tot he Workera'Cono esitimprove000fthe Labor TOTAL:
W (a Cade,you must fo=Ith comply with such provblom or this permit shall be
> deemed revoked. BUI DING E
CL p CONSTRUCTION LENDING AGENCY SEISMIC FEE
= Z Ihereby affirm that then be construction lendingagency fortheperform
ance of the work for which this permit b Issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
O 0 Lender.Name PLUMBING FEE
LL F Lenders Address QTY. MECHANICAL PERMIT FEE
O w Imrtlfythatlhave readthbappliattonand ttethattheaboveinfomutlon MECHANICAL FEE
1 Incorrect.I agree to comply with all city and musty ordinances and state laws PERMIT ISSUANCE FEES PAID:
U) relating to building mmtruction,and herebyauthonre representatives ofthb
F Z city to enter upon the abovementioned property for inspection pa rpmes. ALTERORADDTOMECH.
V — (We)agree to save,indemnify an d keep harmless the City of Cupedine Date ReCei tM
against liabilities,judgments,mats a fid expenses which may In any way accrue AIR HANDLING UNIT(ED 10,000 CFM) P
aBaisytSsaid Cl sequeomofthegra sting oftMsperms. SUBTOTAL:
��G�� MR HANDLING UNIT(OVER IO,WOCFN) CONSTRUCTION TAX
Signature of Applicant/Contractor '- Date EXHAUST HOOD(W/DUCD CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haaardous HEATING UNIT(FO 100,000 BT1n
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date ReCei t#
kte❑alth and Safety Code,Section 25532(a)r HEATING UNIT(OVER 100,000 BTU) TOTAL:
Yes ❑No
Will the zppllant Orfutumbuilding Occupant use equipment or devices VENRLATIONFAN(BINCLE RFSIU) ISSUANCE DATE
which emit harardous air contaMsunts as defined by the Bay Area Air
Quality Management District? BOILER-COMP OHP OR 100,0(10 BTU) BSI D
4 Yrs ❑No PY
have read the h iciaQ Osmucnals mquimments u Oder Cha pier 6.95 of BOB-ER-COMP(OVER 100,000 BTU)
the Gll(ornu Health&Safety Code,
Seer
25505,25533 and 25539.] WAR 16
understand that if the building does not currently haveatenanL that ltbmy NEW RESIDENTIAL MECH. SQ.FT. �(]esas,
responsibility to notify the occupant of the mquiremcob,which most be met 9sx9JC
prior to Issuance of a Certificate of Omspamy.
CITY U t'I rtni Btv
Owner or authorsud agent Date
TOTAL: ISSUED BY:
OFFICE COPY