23599 APPLICANT TO FILL'IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
- BuildingProject Identification PERMITNO.
Queding dd mas: 23599
.
roe s , 6LAn £Y ewe
ners Name: one: A11111,100 ION SU OMI I I A
Join d Imex7 ��Ge7/S CITY OF CUPERTINO-BUILDING DIVISION
Contrador'e Name: a(D 7 b k.LNO: APPLICATION / PERMIT
Rim L/ (r SPPG &LISTS IAIC. BUILDINGELECTRICALPLUMBING-MECHAMCAL CATEGORY CON ROLN
Architect/Engineer. Lk.NO;
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE �71 1K ❑
LICENSED CONTR under provisions
[batch yion7000)of Division
underrpessand so(Chapter
ssions9ds,and c APPLIANCESREEDENTfAL OB DLSCRR''HON
IngwithomexhSedfull force
efflon3ofthe8uslneaeand ProtekloneCode,and my
liters Isla(uLL force and effect PANELS m
License Clam le.if
Date ContractorIM TO 200 ANTS
ARCHITECTS DECLARATION 201-IMO AMPS -
q�v 04 COC I understand my plana shall be used as public records. OVER 1000 AMPS SQ..FLOOR;EA $/SQ.FI.
ku(0 Licensed Pmfeklaral SIGNS ELECTRICAL N
6µ OWNER-BUILDER DECLARATION N�
{"n SPECIALCIRCUIT/MLSC {`� K '
ZL, Ihercby affirm that[cum exem)N(romthe Contras Ion's Llcens law(orthe
oo following reason.(Section 7MI.5,Business and Professions Code:Any city or
O Z i TEMP.MEIEROR POLEINST.
FE � countywhkh requlresa Issuance,
the
, applicant for
��
anya signed
tatemeprior to lteIssuance,almnsedso pursuant
to the provisions
ofpermit e POWERDEVICES DATE
rYG file a signed e[etement that he Is licensed pursuant to the proNsiom of the
Dµ Contractor's License Law(Chapter9(commencing with Section 7000)o(Divi-
In SWIMMING POOL ELECTRIC
�0� al.the basis for
theaek and Prof prion. Any)orlationthat f sxemptection hercfromany �y1a VALUATTOpI/4�'
O the basis for the alleged exemption. Any violation of Section not m by any OUTLETSSWITCI IFSflJ(71)RFS O a.�y 0 CV,��
appBcantfor a permit subjects the appecanttoarnll penalty of not rtkre than � { OC/
five hundred delta=($SM. NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
�n ❑1,as owner of the property,or my employees with wages as their sole
compensation,will do the work and the structure Is not intended or offered for
Osale(Sec.7044,Business end Professions Code:The Contrador's License Law
does not apply to an owner of property who Wilds or Improves thereon,and OCC.GROUT' RFS UNITS
who does such work himself orthrough his own employees,provided that such
Imp'. am.ntsarenotintendedorofferedforkle.ILhowsver,thebulldingor TO
Improvement Issold within one year ofc.mpld(on,the owner-builderwill have
thaburdeno(provingthathedid not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
M L as Owner of the properly,am exclusively contracting with licensed PERMIT ISSUANCE
commetore to construct the project(Sec.7014,Business and Pmfekiok Code: /
The Contractors License Law does nd apply m an owner of property who ALTER
Wilds VEM-
Wllds or Improci
ves thereon, and who contracts for such pTojes with a WATER BEA)
cgn(pctor(s)[incased pursuant to the Contractor's License Law. FEE SUMMARY
I am exempt under See B&P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y N
.
Owner Dare RECEIPT N
WORKMAN COMPENSATION DECLARATION W21ptt. ES PER 7RNa �.. SC[i00l TAX Y_ N_
❑I hereby affirm that I have o Insurance
of consent to oself-insure,thereof ora RI:CER'T N
certificate o(Workess'Compereau.n lnsurana Ora certlflM copythere0((Sec. GAS EA.SY9TEM.1 INCA OUTLETS PARK FIE Y N
380D,Lab C.)
Polity p RECEIPT M
GAS F.A.SYSTEM-0VER 4(EA)
CO aaKi J'�a ^ BUILDING DIVISION FEES
BCertifisd copys�6erebytumIs GREASE/INDUS'IRL WASTE INTERCEPTOR PLANCHECKFEE
QCertified copy ls filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WOR KERS' GREASE TRAP PAID
COMPENSATION INSURANCESEWER-SpM.I•pRY-SNRM Ep 200F1. Date I Recei t#
(Thissed..naed nut be completed if the permit is torose hundred dollars
($101))or lass.) , WATER HEATER W/VENT./ELecIII ENERGY FEE Y N
I mrtifythat In the performance of the work for which this permit is Issued,
I shall not employ any person In any manner an as to become subject to the WATER SYSTEM/TREATING
Workers Compensation Laws of California. Date PAID
Q Z NOTICE[ - NEW RESIDENTIAL PLMB. SQ.HT. Date Recei t#
Z O NOTICE co APPLICANT:IfWork rs'Comh natio icke of Exempt cL,W
should become subject Rothe Workeri Compeisatl.n P.11te.(the Labor TOTAL:
�'T f, Code,you=at forthwith comply with such provisions or this permit shall be IN •E
W > deemed revoked.
IL CONSTRUCTION LENDING AGENCY SEISMIC FEE
Iherebyafflrm thattherelsa construction lending agency for the perform- ELECTRIC FEE
7 Z ance ofthework(orwhkhthia permit la Issued(See.30W,CIv.C.)
(,) O' Lender's Name - r— PLUMBING FEE
LL E- Lenders Address QTY. MECHANICAL PERMIT FEE
O W Icertifythztl have readthis applicatlonand atatethattheaWvelnfornutlon MECHANICAL FEE
a iscomet.I agreeto comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
r W relating to building mwtrudion,and hereby authorize representatives of this
H Z city to enter upon the above-mentioned property for Inspection purposes. AL=ORADDTOMECH. Date Ri f#
(We)agree to save,Indemnify an d keep harmless eCeP
the City of Cu pectin.
V against Bab les,judgments,costs and expenseswhich may in anywayaccrue, AIR HANDLING UMC(TO 10,000 CFM) SUBTOTAL:
agalret k C ty in consequence of the gran 'g of this It '
_ AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
IgnaN Appllunt/Contra or Data IXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,(UD BTU) Date Recel t
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 2SS32(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAIE
❑Yes r!No
Will the applicant or future Wilding cocupant use equipment or devices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Qua llty Management District& BOILER-COMP DEEP OR 10,000 BTU)
❑Yes � '
(have read the bee us materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,D00 BTU)
the California Health&Safety Code,Sections 25505,25533 and 75534. 1 p
understand that if the building does not currently have a tenant,that it Is my NEW RESIDENTIAL MECH. SQ.FT M,�� n Q
responsibility to notify the occupant of the require
requirements which=at be met r 29
priorIssuance ofaCertl(ica of O<cupanq. -
- 29-sz C vv
nor out .rived dgent Data ISSUEDBY:
TOTAL:
OFFICE COPY