23625 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project' PERMITNO.
Building Address: 4Tr
JLo � G
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nets ams: n one:
A, CITY OF CUPERTINO-BUILDING DIVISION fig,— J
Cone eor'a Name: Lac.Nm APPLICATION I PERMIT — J
'� BUR.DINC-ELECTRICALPLUMBINGMECHANICAL CATEGORY CONTROL#
A Itect/Engineer. of Lie.Na
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: o L PERMITISSUANCE ❑ ❑ ❑
PLUMB MULH
LICENSED CONTRACTOR'S DECLARATION
I hereby aHlrmthat l em licensed under provisions of Chapmr9(mmmme. APPLIANCESRRSIDENTIAL ]OB DESCR1Y
Ingwlth Se,fttlI W)o(Dlvcfect oflhegudnessand ProleaslonaCade,and racy - r'\�� r7r��
IFIION
Ilanse b in tu' d dfect, / PAIJQS Y/vy✓� Yy
Limn Clam Llc.# ✓
Dale + Contractor LUP TO 2DO AMPS
ARCHITECTS 'as RATION OVER
AMP"'
�Q'2 Iundentand my plans shall be used as public records � OVER IOW AMPS SQ.FT.FLOOR AREA 5/SQ.FC.
O
LNLicensed Professional SIGNSELECTRICAL '
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/M75C ' N
Z l..,'4 1 hereby affl mthat l am exempt fromthe Contractor's Limme Law fm the
KHfollowing reason.(Sectionrmittoostnessand Professions Code:Mycity Ir V R
— ceuntywhkh requires an7031roconstmct,aid Proprovgdeode:Any city or TEMP.METER OR POLE INST.
any structure prior to its Issuance,also requires the applicant for such permit to pOyyp-R DEVICES
O
file a signed statement that he V licensed pursuant to the provisions of the
Contractor's License Law(Chapter 9(commencing with Section 7000)of� Dlvl- SWIMMING POOL ELECTRIC LUATI�s cion3oftheBusinessandProfealossCode)orthatheIsexempttherefromand
Q the basis for the alleged exemption. Any violation of Section 7MIS by anya,' asses
OUTLETSSWITCFIESFI%'IVRFS
applicant fora permit subjects the applicant to a civil penalty of net more than
If undred dollars($SM.
61,a.owner of the ro NEW RES DENRAL ELECIR Q.Ff. STORIES =CONSTRUCTION
�n p work,
or my employees with wages r ffetr sok
Ocompensation,will do Business workandlheatmce;Th wtntendedLofferedfor
doe not apply to Business owner
Professions Code:TheCImproves License Lw
l3 don not apply torn owner ofprough his who builds orlmproveathercoAand
who does such work himself or through hbown employees,provided that such OCC.GROUP RES.UNITS
Improvements are not intended oroffered forsale.If,however,the bulldingor TOTAL:
Improvement ftsold within oneyearofcompldbn,the owner-budderwill have
thnikurdet of proving that he did notbuilderimproveforpurposeofsele.). PLUMBING PERMIT FEE FLOOD ZONE APN
U L as owner of the property,am exclusively contracting with licensedPERMIT ISSUANCE
contractors to construct the prefect(Sec.7044,Business and Professions Code: '
The Contracto/s License Lw don not apply to an owner of property who ALTERDRAIN&VENT-WATER(EA)
builds or Improves thereon, and who contracts for such pkojects with a FEE SUMMARY
+ctor(e)licensed pursuant to the Contractor's License Law.. BACK FLOW PROTECT.DEVICE
LJ I am ezempt under Sec. B&P C for this reawn
DRAINS A,FLOOR ROOF,ARECOND. SANITARY Y N
Owner Date RECEIPT p
WORKMAN COMPENSATION DECLARATION FIXNRFS PER?RAP SCHOOL TAX Y N
4 ❑I hereby affirm
that I have•carlificatec of consent to op(them,ora RECER'1'N
ani,!celeofWerk<n'Compensation lnsuranceoracenlfkd copythenrof(Sm. GAS FA.SYSIEM.1 INCAOUTLETS PARK FEE Y N
P.3BW,Lb CJ RECEIPT
On By
N GASEA.SYSTEM-O #(
VERFA)
' Cny BUILDING DIVISION FEES
I I Certified copy is hereby furnished, GREASE/WDUSTgtL WASTE INTERCEPTOR PLANCHECKFEE
Certified mpy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SAMTARYSIORM EA 200F1' Date Recel t#
(Thlssectlon need not be completed tithe permit V forom hundred dollars
MOD)or lase.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N
I cerd(ythat in the performznceof the work forwhich this permit Is Issued,
I shall net employ any person In any manner w as to become subject to the WATER SYSIEM/TREATING
Worken'Compensalion Laws of California. Date - PAID
ZZ Applicant NEW RESIDENTIAL PLMB. SQ.Fr, Date Recel t#
O NOTICE TO APPLICANT-.If,after making this Certificate of ExemPit on.you
should become Subject to the Workers''Compensation provisions of the Labor TOTAL:
F N Code,you moat forthwith comply with such provisions orthis permit shall be
j deemed voiced. BUILDING
FEE
LU CONSTRUCTION LENDING AGENCY SEISMIC FEE
0. IherebyafRrmthat them I"constmctlon lending agency for the penornry TOW. ELECTRIC FEE
M ZO Lan.of the work(.',which this permit I,ewmI(Sec.3097,Civ.C.)
nderb Name PLUMBING FEE
LL 1= bender'.Address QTY. MECHANICAL PERMIT FE6 MECHANICAL FEE
O W Imnlfythailhavenadthbapplk tbnendetatethattheabovelnfom im
IL to correct.I agree to comply withal city and county ordinances and gate[am PERMIT ISSUANCE FEES PAID:
>. relating to building construction,and hereby authorize representatives of thin
F N city to enter upon the above-mentioned property for lrapedlon purposes. ALTERORADDTOMECH.
? Me)agree to save,indemnify an d keep harmless the City of Cupedlno Date Receipt#
V aganat liabilities,judgments,costs and expenses which may In any way accrue AIR HANDLING TWIT GO 10,000 CFM) SUBTOTAL:
.S.ug said City N consequence of the anring of this permit. AIR HANDLING UNIT(OVER IO,WOCEM) CONSTRUCTION TAX
^ - CONSTRUCTION TAX PAID:
Signa roof Applicant ontractor Date EXHAUSI'HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE
Will the appBcant orfuture building occupant store or head Is hazardous HEATING UNIT(TO 1Wy000 BTU) Date Recef I#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
Health and Safety Code Sectloo 25532(x)7 HEATING UNIT(OVER IW,WO ETU) TOTA /—
❑ye' M No
Will the appllaM orEtma building occupant use equipment or devi¢a VFNIILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hamrdous air contaminants as defined by the Bay Area Air
Q�L,llty Mamgcment District? BOILER-COMP OFm OR 100,000 BTU)n
Yp�
nNo T
Y.
read the hassr1oua materials requirements underChapier6.95 of BOILER-COMP(OVER IW,OWBM
the Callfomla Health&SafetyCode,SMbns 25505,25533 and 25534.1
understand that if the building don not currently have ameant,that It is my NEW RESIDENTIAL MEC#. SQpT 9AY as
� ���
respom . t
ibilo notify the occupant of the requlremen
b which=at be met
prior to Issuance of a Certificate of Occupancy. CITY U p
fl
Owner or aulhorlred agent Date ISSUED 8Y'
TOTAL:
. OFFICE COPY