23549 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - - PERMIT NO.
Building Address: - 23549
z o�
n rFlunis: AVV�IIUN 5UBMII IAL DAIL
w rQ ams. D CITY OF CUPERTINO-BUILDING DIVISION
Contrace .Name /J� a� Lic.No: APPLICATION-/ PERMIT.
�EY(� ES/6,.1 l.L'a�N r 7 BUIL.DING-ELECTRICALPLUMBING-MFCHAMCAL CATEGORY CONTROL#
Architect/Engineer. Llc.No:
LECTRICiPt,RMIT i',`.FEE .,I '=I BLIILDING;P,ERMITINFO'
Address: - - PFRhIITISSUANCE ..
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provklons of Chapter 9(oommena APPLIANCES-RESIDENTIAL ]OBD SCRIPTION
tngwlth Seciion7 )ofDivlsion3ofthe Businemand PmfessionsCode,andmy -
licence le In fullfo and effect. PANELS
LimDat case lam LicContractor' UP TO 200 ANTS
roHT '��
ARCHITECT'S DECLARATION 201-1000 AMPS
rs am Z I understand my Pismo ehzll be used v public remnis. OVER 1000 Ah4I'S i, r. {Q�I�FL AREA 3/SQ.Ff.
Wz Licensed Professional - - SIGNS ELECTRICAL ,( _
Q OWNER-BUILDER DECLARATION SPECIALCEiCUIT/M v t ','� ��`, ✓ L.«. 0"" R '
p.,�y 'I herebyafftrmthntlam exempt Contractor's Licence Law for the + -
Z O E.' following reason.(section 7031S,Business and Professions Code:Any city or `
OZI-P TEMP METER OR POLE I ST. '
tountywhkh requires.permR romnntrvuiresthe a prong tfor such,or mitto
P Cal any.trurudantre orto its that he gakensed pursuant to
he applicantfor of the POWER DEVICES
t9��� (Ile a signed statement that he is licensed pursuant to the provkiow of the
W63y,I. Contractor's License Law(Chapter 9(commencing with Section 7000)of Div'- SWIMMING POOL ELECTRIC
EO;}- sion3 ofthe Business and ProfaxaImaCode)orthat he kexempttherefromand VALUATION
O the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCI-]ESHX7URES.
applicant fora permit sub"the applicantto a civil penalty of not mamthan
five hundred
owner
thi pro SQ,FT.- STORIES TYPE CONSTRUCTION
'9..'
compensation,I,ae owner o!the•property,or my employees with wages ae their sole NEW RESIDENTIAL ELECTR
will do the work and the structure k ac Intended or offered far
sale(Sec.7094,Business and Professlmw Code:The Contractors License Law
S does not apply to an owner of property who builds or'mprovea thereon,and OCC GROUP RES.UNITS
who doessuchwork himself orthreigh histimemployeea,provided thatsuch
Improvements are not intended oroftered forsale.If,however,thebuilding or TOTAL:
Improvement Lssoldwithlnoneyearofcompletion,the mvner-bullderwlllhave
tli0-L,+rden of pruning that he did not build or Improve for purpose o(sl ) Q'j'y; +';'''. gPLLJMBINGtPERMIT '�iFEE"..' FLOODTANE APN
I L as owner of the property,am exclusively mntra.Hng with iicenseti
contractors to construct the project(Sec.7044,Business and Professions Code: PERMIT ISSUANCE
(13
The Contractors Licence Law does not apply to an,owner of pmperty who ALTER &VENT-
Wilds or Improves thereon, and who contra-for such pt,ojroa with a WATER CEM
CgDtt dor(s)licensed pursuant to the Contractors Licence Law.
am eBACK FLOW PROTECT.DEVICE FEE$UMMARX, ,:'t'
i_I I xempt under See. B&P C for this reason
Owner _ DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Date RECEIPT p
WORKMAN COMPENSATION DECLARATION FD(T RE4 PER TRAP SCIgOOLTAX Y— N—
❑I hereby affirm that I have o Insurance
of concent to opy thereof
ora a RECD,#
MCcer0,Labicate of Wdrkers'Comper,eatlonlruurence oremrtifled copy thereof(Sec. GAS F.A.SYSTEM.1 �'
3500,Lab CJ PARK FEE Y— N—.
Policy If GAS EA.SYSTEM-OVER 4(EA) RFCEBxf p
Co any BUILDING DIVISION FEES
[Certified copy is hereby te
Certified copy kfiled withh the city
impaction division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCI-IECK FEE
_ � ity
CERTIFICATE OF EXEMPTION PROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARYSTORM EA.200F17, Date Recei t# '
(This sectionneed not he<ompleted if the permit k forone hundred dollars
Mae)or a..) WATER HEATER w/veNr/ELEcia ENERGY FEE Y N
I mrtlfy that in the (ommnce of the work f which this permit is leaved, —
I shall not employ a cram i ray manner as to orre b�ect to the WATER SYSTEM/TREATING '
Workern'Compen I Law Gli(OIn e ` 2Z' _ PAID
-
zZ - NdTICnt NEW RESIDENTIAL PLMB. SQFI'. Date Recei t#
Z O' NOTICETO ;U,after-akin 1 s ertl(Icete of Exemption,you'
should becomes tothe Works m atton provisions of the Labor - TOTAL-
Code,Code,you mu at forthwith comply echprovkloro orchis perMtshall be BUILDING J deemed revoked.
W
C CONSTRUCTION LENDING AGENCY - - SEISMIC FEE '
I herebyaffirmthat there Is a construction lending agency for the perform- ELECTRIC FEE
M Z ante of the work for which this permit is Issued(Sec.3097,Civ.C.) T ^� _
V O Lender.Name ^ PLUMBING FEE �*
LL F Lender.Address QTY. ? ;MECHgNICAL PERMIT :%FE$•;^ MECHANICAL FEE
O W Icertlfythatl have readthkapplicatlonand statethatthe aboveInformation
IL is mrmct.]agree to comply with aBcity and countyordinancenand nate laws I PERMIT ISSUANCE FEES PAID: -
} N relating to building construction,and hereby authomeereprecentalive.of thk ,
F Z city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH. Date 'Recei t#
(We)agree to save,indemnify an d keep Iu em the City of Cupertino - P
against liabilities,ud nts,rostsand expenx hkhmay'nanywayaccrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agaioatsmd Cityl saquen fthe grant) of th ertnit.
7devime
NR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX' _
Signature of ontractor EXHAUs'r HooD(w/DUCT) CONSTRUCTION TAX PAID:
n Von 9DISCL
Will the applicant or future building occupant sit zardous HEATING UNIT CED 100,000 BTU) Date
material as defined by the Cupertino Municipal Cod e, and the Recei t#
Health and Safety Code Section 25532(a)2HEATING UMT(OVGR 100,000 BTU) TOTAL:
❑Yes M No
Will the applicant or future building occupant use eevime VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which emit hazardous air contaminants as defined by tirp� �Qu❑a lity Management DisMct? BOILER-COMP(3HP OR 100,000 BTU) PA7 YesF�u +
have read the hazy smaterlab requirements under Chapter 6.95 of BOILER-CC 100,000 BTU) ar�
the Giifornk Health&Safety Code,Sections 25505,25533 and 25534.1 N D q ���
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQXT. 1{ far
reepornibility to notify the occupant of the requirements which mustbemet �' C�7Y Ur
prior to issuance of a Certificate of Occupancy. _ _ \ � (J� UU�rttl ,IVU
Owner or authorized agent Date ISSLIEDBY: 1 " - '-' h�•j^^'JJJ
TOT
OFFICE COPY