23729 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Address: n N� n n
0too G3 29
one: A
V1Ld�V CITY OF CUPERTINO-BUILDING DIVISION �LZ
c rs me: a=•N ' APPLICATION /PERMIT D
Arc Iters/En neer. 'BIIILDINGELFGTRICALPL B) MECHANICAL
CATEGORY CO11 X
.l Lk.Na
~ QTY ELE ERMIT FEE BUILDING PERMIT INFO
Address:
LICENSED CONTRACTOR'S DECLARATION FERMI CE ❑ El El
I herebyafflrmthat lam licensed
underprovslonsf Chapter9(ce w �JOB�DESCRIPTION
hecionfDivision ftheBuslnemand ProfnalomCode,
Itcenaelel.f.11fitedundefet.
ANELS
License Clam Lk.N
Date Contractor ( 1
ARCHITECTS DECLARATION NI-1 v
q�q�vv M, lundentandmypbwahaUbeuwdmpubllcmen A. OVIRI SQ.Fr.FLOOR AREA f/SQ.FT.
k o Licensed Professional SIG CAL
<< OWNER-BUILDER DECLARATION S['ECIAL CIRCUIT/MISC
Ihembyaffimtbatlamexempifromthe Cont.d.e.Licenm Uwforthe
following on.(Section 7031.5,Business and Professions Code:Any city or
O
coon which Irma permit locemtru alter,improve,demolh p TEMP.ME[ER OR POLE INST.
t4, requ pe R p h,arre air
ne atmrturc pdement hauncgaW requ pursuant to the fosuionsch ofNt a POWER DEVICES
O Edea actors License
that he to licensed pursuant it the provh Section isions of the
ud� Ion3ofthe Lige Low(Chapteremi 9(commencingmCode)orthat eisemmptthemfmmof ivi-
�� S slon3 orthe 8uminm-and Professions Code)orthal hebexemptthere(romand SWIdMING POOL ELECTRIC VALU�— '
�s the basis for the alleged exemption. Any violation of Section 7031S by any
<5
applicant lots permit subjects the applicant to Advil penalty ra nor more than OUTLETSSWITCIIESF[XTURES LrJ
five hundred dollars W00).
❑I,as owner of the ro NEW RESIDENTIAL ELECTR SQ}7; STORIES TYPE CONSTRUCTION
p perry,or my employees with wages as their cele
s.'l< compensatlonwUldo the work and thestrunure b not Intended or offered for
Y�' O sale ISM 7044,Business and Professions Cade:The Contracioe.License law
does not apply to an owner M property who Wilde or Improves thereon,and OCC.GROUP RES.UNITS
GG who does much work himself orthrough his own employees,provided that much
improvements are not intended oroffered for-ale.If,however,thebuilding or TOTAL:
improvement isaoldwithinoneyearolcompletion,theowner-bullderwlll have
thg�urden of proving that he did we build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
u Sas owner of the property,am exclusively contracting with licensed C
contractors to construct the pmject(Sec 7044,Business and Proremlans Code:
The Contractors License law does not apply to an owner of property who A I
Wilds or Improves thereon, and who contracts for such pta)ects with a FEE SUMMARY
c ntractar(s)licensed pursuant to the Contractors Lt...Law. B W E
I_l I am exempt under Sm B&P C for this reason MIN
DRAINS FLOOR ROOF, SANITARY Y N�
Avner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FI( SCHOOL TAX Y_ N
❑I hereby Affirm,that I have•certificate of consent to op(thmmo,ora RECEIPT X
3800,UbC.certificate of Worken'Compensation lnsurance oracertlfled copy thereof(Sec. GAS EA.SYSTEM-1 ING4 OUTLETS FARKFER Y N
3800,Lab C.)
Pralry p GAS PA.SYSTEM-OVER 4(EA) RECEIPT N
a Y BUILDINGDINGDDI VISION FEES
Certified ropy b herebyththshed.
CertCREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFECertifiedcopy is filed with the city division. LJ ��
CERTIFICATEOFPXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-SfORMEA 2DOFT Dat CCYI [#
(This section need not W mmplcted If Ne pemdt b(or one hundred dollar
(5100)ofy that
WATER HEATER W/VENT/E].ECTR ENERGY N
I certify that N the performance of any
manner
w as to h co permit
subj V Issued,
I shall not employ any person In any manner at ss m become subject to the WATER SYSTEM/TREATING PAI
Worker-'Compensatbn Laws of California. Date
O Z Applicant this you NEW RESIDENTIAL PLMB._SQFT. Date Recei t#
Z O NOTICE TO esuPbjCttothe eRermakingpessationlprovicate omoftEcmpel.b.
P Code,you=at
mb�ctto the Workers'Comp rovisinprovhis per it shall
IOTA
WLD dmmeelounoked. with comply with such provisions orthla permit shellbe BU E �X
> a[emed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Iherebyaffirm that there Ua construction lending agency for the perfoms- ELECTRIC FEE
J 0 ance of the work forwhlch this permit 9 Issued(Sec.3097,Civ.C.) TOTAL. ELECTRIC FEE
V I-oder'-Name
LL F— Lenders Addmea QTY. MECHANICAL PERMIT 1'GE MECHANICAL B
OW 1certlfythat l have read thisappUcaHonand statethat theabovelnformatlon
W tacomot.I agmeto comply with all city and county ordinances and pate lawn PERMIT ISSUANCE FEES PAID.
>. relating to building construction,and hereby,autho me,representatives of this
I.- fA city toenteruponthe above-mentioned property for Inspection purposes. ALTER ORADDTO MECH.
Z (WOagreet mve,indemnilyand keep harmless the City of Cupertino Date eceipt#
V againsthabilil Ndgmenta,cosuandexpenm.whlchmayln anywa accrue AIR HANDLING UNIT(TO IO,ODOCFM) SUB OTAG
against said! In con-eyu rear IPg oftN.permitpermitt AIR HANDLING UNIT(OVER I QODO CFM) CONSTRUCTION TA
s nature pp8ant/ tractor D a EXHAUSTHOOD(W/DICT) CONSTRUCTION TA PAID:
HAZARDOUS MATERIALS DISCLOSURJ
Will the applicant or future building occupant store or handle haeardous HEATINGUNIT(70]00,0008TIZ
traterial..defined by the Cupertino Municipal Code,Chapter 9.12,andthe _ Date Regie t
Health and Safety Code Section 75537(.)7 HEATING UNIT(OVER i W,0 X1 BTU) TOT
❑Yea r]No
Will the appllmnt orfutumbuildingoavpant useequipment ordevices VFN'IILATIONFAN(SINGLERESID) ISSUANCE DATE
which emit hazardous air contamlnanb as defined by the Bay Arca Air
Quality Management District? BOILER-COMP(3HPOR 100,000 BTU)
4Yes ❑❑No
h.we reed the hazardous materJalsmquirer ntsunder Chapter6.95of BORER-COMP(OVER 100,000 BTU)
the GUfornia Health&Safety Code,Sections 75505,75533 and 23534.1 PAID
undmtand that lithe building does not curnntly haveatenanL tlwtitbmy NEW RESIDENTIAL MECH. SQ.FT.
_ responsibility to orally the occupant of the requirements which must be end
prior to Issuance of a Certificate of Occupancy. wl,
Owner or authorized agent Date ISSUED� I .8
OTAL: —
OFFICE COPY