23849 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: -
23849
� o D
A
Hera , one CITY OF CUPERTINO-BUILDING DIVISION
40 Fact d ' N APPLICATION' PERMIT (9
BUILDINGELECTRICALPLUMBI G-MECHAMCAL CATEGORY CONTROL M
Architect Engineer. Lic. ce '
QTY. :i t . HL�CfTR • RIvIIT tit ` ;FEE ,',:"BUILDING PERMIT, ,•:,:1 ;
Address: -
�, PER ITISSUAN. tj
•�"' .
LICENBillSED NTRACFOR'S DECLARATION
I herebyaffirm that Bcensedunder provlsloneof Chapter 9(commend APPLIANC DENTIAL JOB DESCRIPTION
ingwith Eft
vilon3ottheBwiaesand Pro(eseloaC.ome,and my �
license isinfuEforce, rd effect P IlJ{7^V'LI�3
License Cla LION
Dat .Contractor
ARCNITE7S DECLARATION - 1'1000 PS
Q❑O I undentan y pea shall be used as public records. OVER 1 r F]D' R AN
F]s�l 1 , g/ Q:
tJ' Licensed Professional " - 9CNS E CAL_ ,V" •tl 1 Y
«$ m$ OWNER-BUILDER DECLARATION SPECUL CULT/ - I� 11 T E ff�
2t, � I hereby affirmthat I am exempt fromthe ContractoreLiceae law for the
F9;:� .a following reason.(Section 7031.5,Business and Professions Code:Any city or
t9+ cmntywhichrequiresapermittommtmd,alwpimprove,demolish,orrepair TEMP'M RPOLEINST.
g ,a anystmmmprior Mitetmance,abonquimsiheappli=tforsuchpermitto POWER ACES ATE
L{ file a signed.statement that het licensed pursuant to the provisions of the
Contractor's License law(Chapter 9(commencing with Section 7000)of Divi- -
s SWIMMING POOL ELECTRIC -
ES ab basis fo the s ea e d Profession. Any)inhalers f section MI.5 by any VALUATIONQ�j
O the barb far the alleged exemption. Any violation of Salton not m by any OUTLETSSW[TCHESFappIXTURES O ' ^
five handred fort permit s($300ene the applicant los civil penalty of not moretlun 'JV �X/�•J
$ five hundred melon he pr. NEW RESIDENTIAL ELECTR SQ,FF. STORIES TYPE CONSTRUCTION
�n ❑I,as owner of the property,or my employees with wages r thele coo
compensallon,wW dothework andtheatacture isnot Intended or offered for
Oask(Sec.7094,Business and Professions Code:The Contractors License Law _
$ does not apply to an owner of property who builds or improves thereon,and - OCC.GROGIx RFS.UNITS
who does such work himselforthrough his own employees,provided that such
Improvement are not intended oroffered for sale.If,however,thebuilding or O
i provementbsoidwithinoneyearofcompleliov,theowner-budderwlll have n
ftlyurden of proving that he did not build or improve for purpose of sale.). FIppD TONE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors W conetruct the project(Sm 7074,Business and Professions Code: �►
The Contractors License Law don net apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or Improves thereon,and who contracts for such projects with a
cqutlactor(s)licensed pursuant to the Cmtiator'sLima.Law. •$ ,Ei$UMMARY,'.
IJ I am exempt under Sec B&P C for this reams, BACK FLOW PROTECT DEVICE
DRAINS FLOOR.RODE,AREA,COND. - SANITARY Y_ N—
eI r Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL FAX Y— N—
❑ hereby affirm that I have a certlfirate of consent to self-Insure,ora /-' I RECEIxT N
certRlatofWorken'Compersatlonlaurance oracertifled copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS
Polis lab C.) PARK FTE V— N
Com an GAS EA.SYSTEM-OOVER BUILIf I DING DIVISION
,_,P Y _ BUILDING DIVISION FEES
LJCertifiedcopytfiledytumthed. GREASEANDUSTRL WASTE INTERCEPTOR PLANGHEGK FEE
Certlfed copy b flied with the tltylapectlon dlvtion. t" 43
CERTIFICATE OF EXEMPTION FROM WORKERS'. GREASE TRAP PAID Pi L
COMPENSATION INSURANCE SEWER-SANITARY-SIORM EA.200Ff. Date Rectit#
- (Thissectionneednotbecomplowdifthe permit lafmma hundreddolian
($100)orlenJ -
Icertify that In the performance of the work for which this permit is isWATER HEATER W/VENT/ELECTR ENERGY FEE Y
Issued, - N+
—
I shallnot employ any person In any manner m u to become subject t°the WATERSYSTEM/TREATING
W°rkers'Compensationlaws of California.Date - PAID
-
zZ Applicant Date Recei t#
Z O NOTICE TO APPLICANT:If,after raking this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ,Ff.
should become subject to the Wmi am''Compersatlon provision of the Labor TOTAL:
tl7 Code,you must forthwith comply with such provbiors orthb permit shall be
> deemed revoked. - BUIL IN FEE
M Z anon ofthe work for which this permit Is ie
(L — CONSTRUCTION LENDING AGENCY- SEISMIC FEE
a.G Ihereby affirm that there ba construction lending agency for the perfrn, ELECTRIC FEE
Issued(See.3097,Civ,C.) L /�
02 Lender's Name PLUMBING FEE �—+
LL F ndersAddressHtJECHgNIGAL''PER141ITt FES.t,;' MECHANICAL FEE
O W Icerti/ythatl havereadthb application and statethattheabovein(ormatlon
bcorrect.I agreetncomplywith all cityand countyordlnaoces endstatelawe PERMITISSUANCE �� FEES PAID:
de
fl relating to building roarruction,and hereby authorize representatives oftho
F Z city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
(We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
V agafrstllabI es,ydgment,costs and expenses which may In anywayaccrue AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL:
against ea In cone u m f grantingofthopermit. �
(-JnAIR HANDLING UNIT(OVER IO,000CFM) CONSTRUCTION TAX
SI ature of Appbcant ontr
/Cactor - Da - EXFLIUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA2" US ATERIALSDISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UMT(TO 100,"BTU) Date •Revel #
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER IOO,OW BTU) TO
❑Yes �No I '
Will the applicant orhitom building occupant use equipment or devicesVFMIILATION FAN(SINGLE RESID) P s[S�U�ICE DATE
which emit ha,canlous air cot ntaminanas defined by the Bay Area Air /4
Quality Management District? BOILER-COMP(3FIPOR 100,000 BTU) —
4Yw �No
havereadthehaza auematerialsrequimmntunder Chapler6.95of - BOILER-COMP(OVER 100,000 BTU) UN �� "'
the Califomla Health&Safety Code,Senrs to"
o25505,25533 and 25539. I,
92
understand that lithe building dues not cmmotly have a tenant,that itis my NEW RESIDENTIAL MECH. SQ.FT J
responsibility Issane nfatytheicte ofI ccupa requirement which most be mat QurCI'i I'lu
reiponsissuance otif a ytheoaleoftofthereq C11Y
Owner or aulhotlzed agent - ,DateyY.'���.(yf���'�i '
TOA ISSUED B".�—'—I
OFFICE COPY