23622 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PEILMITNO.
Building Address: - 23622
16S�6 L _ 1.
Owners one:
A A A
♦d� >✓ 409 Ids—S3q CITY OF CUPERTINO-BUILDING DMSO \�.� `Ci
Contractor'sName: Lie.No: APPLICATION / PERMIT L
BLnDINGELECTRICALPLUMBINGM ) CAL CATEGORY CONTROL"67
4 q
Architect/Engineer: Llc.No: G7
QTY 'ELECTRIC R __gEZ
BUILDING PERMIT INFO
Address: nls�JSSLJAN
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commenc- APP DENTIAL JOB DFSCM-ITON
iogwfth SeRion7000)of Division3 ofthe Businessand ProfessionsCode,and my
license is In full force and effect. PA
License Clan Lic.N
Date Contractor
ARCHITECTS DECLARATION 101-10DOA.MPS
a2. I understand my plans shall be used as public records. OVERl"AM SQ.FT.FLOOR AREA $/SQ,Fr.
otd6{�O // e
Licensed Professional SIGNS ELEC AL l' 2S 6�S•• (6 '�• 36
<XwOWNER-BUILDER DECLARATION •/-1
I"" F, SPECIAL CIRC /M15C �1
tQC�E Iwmgneff .(Sraen70a`empt(romthe ContractorsLicense taw for the
70..-- f.lJcmnt which quimsa pe tiocusiness tmd, nd Professionsemle hnydtyor _ Y31:z_ i
O 7-i.,u9 TEMP. OR POLE INST. •" l
P49, countywhich rcquiresa permit toconswct,alley unprove,demolish,orrcpair
ggg�'`3Tj¢ a nystri=mpHortoibtssrancgaL requimtheappbmntfurwchpermitto POWER DEVICES ) •� O�
�u�U file a signed statement that he is licensed pursuant to the provisions of the 7 2_ �'T
Oat- Contractors License Law(Chapter 9(commencing with Section 7000)of Divi-
: sion3ofthe Buslnessand PmfessloroCode)orthatheuexemptthemfromand VALEl U
SWQ.4M1NG R70L ELECTRIC
5 the basis for the alleged exemption. Any violation of Section not in any, UTLETSSWITCI-BSHX URE5
applicant for ape rMtsubjectsthen. An violation
adull f Section
yof not=in than ./
five hundred dollars(6500). -
m ® hgSW RESIDENTIAL ELECTR SQ.FT. STORMS TYPECONSTRUCTION
7 or I,as owner 1 the property,oche employees with wages r thele sole
pen.7044,Business and
work andehestmctureh nm intended or offered for
p .sale(Sec.7044,to an
(property Code:Wids Contractors License
ers,on Law (\II n
2 donnotapply to an owner ofproperty who builds orimprwnlhereoR and
F,d.. whodoessuchworkhbruelforthroughhisownemployees,prwidedthatsuch OCC:GROUI?_„ il—
improvements arenot Intended oroffered for sale.I(howevegthebuildingor r•"— / ��/I L� "j
improvement issold withinoneyearofcomplation,theowner-bullderwill have v V, ( 1
thden of proving that he did net build or Improve for purpose of salt.)._ QTY, PLUMBING PERMIT FEE p DZQUE
tV,an owner of the property,am exclusively contracting with licensed pp(MITISSUANCE 1 3 AIMIL
contractors to construct the project(Sec-7064,Business and Professions Cod e: �� DATE
The Contractor's License law don not apply to an owner of property who 1
ALTER-DRAIN&VENT.Wilds or lmprwea thereon, and who contracts for such pgsjects with a WATEA(EA) _
ou trictor(s)licensed pursuant to the Contractors License Law. FEE SUMMARY
I BACK FLOW PROTECT.DEVICE
am nempt der Sec. B&P C for this reason OUTSIDE FELS
_ DRAINS FLOOR ROOF,AREA,COND. SANITARY Y - N
ja Owner Date _ RECEpPN
OR O SATIO DELLA 10 PER TRAP $CIi00L TA% Y_ N_
❑I er afl1 that I have certllicate of consent to self-insure,or a
RECEIPT N
certificat OXTURE
of Workers'Compensid Insuranceoraconifleelcopythemof(Sec.
3800,Lab C.) GAS EA.SYSTEM-11NCA OUTLETS �- PARKFEE. Y_ N_
AECERT N
Policy0 GAS-EA.SYSTEM-OVER .
orn any BUILDING DIVISION FEES
c
�Certifici copy is hereby furnished. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
❑coni ied copy is filed with the city Inspection division. �.I I•Q'3
CERTIFICATEOFE%EMPTION FROMWORKERS' GREASE TRAP PAID-7 (2—_49W
s COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200F1. Date RCeei tit
(This section need not be completed if the permit is forone hundred dollars
(sto0)or lege.) WATERTTRW/VENT/ELECTR ENERGY FEE Y
T _ N_
W).r lythat N the per(ormanm o([hc work(or wM1ich tM1la permit is baed,
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING jam_L�((
Workesa Compensation Laws of California. Date - PAID f.7aa
C) Z Applicant NEW RESIDENTIAL PLMB. SQAT. Date Recei t61
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
'should become subject to the Workers Compensation pmvbiom of the Labor TOTAL: �..
Code,you must forthwith comply with such provisions or this permit shall be •ti
W > deemed revoked. BUILDING FEE 0 •Y'0
CONSTRUCTION LENDING AGENCY SEISMIC FEE .3s
IL Ihereby alit 'hat there b a construction lend ing agency for the perform ELECTRICFEE
M Z ance of the workfor which this permit is Issued(See.3097,Civ.C.)
U O 1<nder's Nacre PLUMBING FEE Lt
IF Lendersm
ndda QTY. MECHANICAL PERMIT FEE
LL O I camlythat l have madthu applicatlonand mate thauM1eabove information / MECHAMCAL FEE
O W, iscorreat.l agree to comply withal)cityand county ordinances and state laws PERMIT:ISSUANCE FEES PAID:
. } 4 relining to building construction,and hereby authcrW,reprnentatives of this
F N city to enter upon the above-mentioned property for inspection purposes. ' ALTER OR ADD TO MECH. --t
Z (We)agree to save,indemmfy an d kee aemles me city of Cupertino Date Receipt#
4U against liabllltin,judg nb,cosisanB ex see which may In any-ayaccrue AIR[iANDLING UNIT(TO 10,1100 CFM) SUBTOTAL:
agaWtsal 'ty in enceofthe rating of this permit.
AI
� �� � R HW
ANDNG IIMT(OVER lO,WOCFM) CONSTRUCTION TAX
Sign plicant/contra Date IXIIAUSTHOOD(W/DIKT) CONSTRUCTION TAX PAID:
HAZAROD MA I RIALS DISCLOSURE
WI)It applicant or future buildin occupant store or handle havaedous HEATING UNIT TTP 100,000 BTU)
1 'PP P DatC CCeI t#
material as defined by the Cupertino Municipal Code,Chapter 9.11,and the
Ileaeh and Safety Code Section 25532(a)I H TING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes L�Ko —
1 Will the applica rat or future building ocu pant use equipment or devices VEMTLATION FAN(SINGLE RESIDE ISSUANCE DATE
which emit havrduus air contaminants as dented by the Bay Area Air I
Quality Management District? BOILER-COMP DtIPOR 100,00D BTU) i.� -
1_F Y's o r pp .
`,have read the hour cases materials requirements under CM1apter 6.95 of BOILER-COMP(OVER 100,000 BTU) W
the California Flcalth&Safety Code,Sections 25505,b533 and 25534. 1 JV
understand that if thebuilding does not currently have tenant that it b my NEW RESIDENTIAL MECIiL SQ.FT A' 7
responsibility to notify the gccvpant of the require which must be met rY 1 O O
prlortoiss ce car'sCe trateofOccupancy., Calc OF I• sJ
Pv roc set .,rff Date - ISSUED BY
OFFICE COPY