23658 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — US L POINT PEN ONLY
Building Project Identification PERMITNO.
Building Address:
23658
TM- 2l(Dol CSW BuS E
nera ares: one: AEFLICAl
LIJ x,LLL CITY OF CUPERTTN0.8UILDINC DIVISION �` A
coning cisme: LiAPPLICATION / PERMIT �7�'1 �Z
�� W a�O T. W S L L S II Ir BLnDINGFLFCTRICALPLUMBINC-MECHANICAL CATEGORY CON 'SS
Architect/Engbaar. Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMTISSUANCE � TCyt
LICENSED CONTRACTOR'S DECLARATION LNC
Thereby affirmthet lamlkansed under provisions of Chapter9(commnc APPLIANCESRESIDENTIAL DESCRII-LION
IngwithSeMon 7000)of Division 3 ofthe Business and Profeulon.Code,andmy ROD/
limb la In full( and cited, PANES '`•r��„!D Mr—IWO
LI LIF ct, L 3 5-
ate Contndor UPT0200AWSr,,RAREA
ARCHITECTS DECLARATION 201-1 AMPS0Iunderstand mypkrashalle used aspublicrecorda - OVERnfOa Licensed ProfessionalSICNSEL i GL
�6 OWNER-BUILDER DECLARATION SPECIAL UTT/MISC 'i
Thereby aL_
7s'Fe'7 ((Ibm that l am exempt from the Contractor's Llrnnse]awforlhe a�
following reaaon.(Seddon 70315,Business and Prekuhm.Code:Any city or
Fcmntywhichmqubesapem ttomn Mn ter,ImpmwdemlWh,orrepair TIMP'Mh1'[ROPALE INSr.
11 abystreciure pdortoln lasumce,also requirmtheapplicant for such pemdtto E%Il
K ilk a signed statement that he is licensed pursuant to the provisions of the
rcI� Contract.e.Lkaaa Law(Chapter 9fcommencing with Section 7000)of kuDivi- SWIrihONC IDOL ELECTRIC VALUATION
BOJ Bion 3 ofthe Business and Prvbb taCode)orlhat heexempt thebefromand '
a.•77 the bash for the alleged exemption. Any Nolallon of Section 703IS by
.by
penalty 1 O O
a ppbantforapermit.bie theapplicanttoadvil penaltydnot more1Wn
five hundred dollars($500). NEW RESIDENTIAL ELECTRS2.FT.
�n ❑1,as owner of the property,or my employees with wages as Iheir able STORIES TYPE CONSTRUCTION
< mmpom.d.,"I do the work and the structure is not Wended or offered for
f O sale(Sm.70M Business and PrufessWm Code:The Commences Lt..Law
does not apply to an owner of property who builds or improves thereon,and OCC GROUP RES.UNITSCC: who does such work himself orthrough his own employees,provided that such
Improvements are not intended or offered for sale.If,however,the Wilding or T
Improvement iseold wlthinone yearafcompletion,the owner-bu0derwill have
t1ijikunien of proving that he did not build or improve for purpose of nit.). QTY. PLUMBING PERMIT FEE
U 1,as owner of the Property,am exclusively contracting with licensed FI-OOD TONE APN
PERMIT ISSUANCE
contraon to coratmet the project(Sm 7044,Business and Professions Code:
d ..�
Th.Cmdom oes Lmme Law does not apply to an owner of property who PETER-DRAIN AVENT-WATER[EA)
Wilde or imprevn thereon,and who contracts for such pq0"with a
cga"Ildoral licensed pursuant to the Contmdoe's Llmnm Law. FEE SUMMARY
L-J I am exempt under Sea B h P C for this mason BACK FLOW PROTECT.DEVICE
Owner Data DRAINS FLOOR,ROOF,AREA,GOND, SANITARY Y -- N_
EC
REIPT R
WORKMAN COMPENSATION DECLARATION gra SCHOOL TAX Y_ N
[-]I hereby affirm that I have a certi0nte of consent m ulf-Insure,ora PER TRAP RECEIPT— NN
certWnfe o(Worken'Compereationlreurance or a certified copy themof&ee.
3800,Lab CJ CAS FA.SYSITM-1 INCA 0UILEIS PARK FEE Y N
Policy a RECEIPT M
CMCan
BUILDING DFVISZQN FEE
edified S
copy hebhed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHEC s�
❑Certlled copy V fileddwith ltM1 the city Inspection division.
GREASETRAP
CERTIFICATEMPE SATIO PTION FROM WORKERS' PAID
COMPENSATION INSURANCE SEWER SANITARY-STORM FA 200P1' ate Recei O �+
(ThIssectlon need not be completed If the permit V forom hundred dollars
($10(fimless) WATER HEATER W/VENT/E.ECTR E YFEE N
I cortRy that in the performance of the work for which this permit is Issued,
I shall not employ any person N any manner an u to . cab to the
Workers'Com Ion la of if.V. to WA�'SYSTEM/TREATING PAID R
O Z Appllant ^ NEW RESIDENTIAL PLMB: � r. Date cel to
Z O NOTICETOAPPLICANT:If,after mokingthk Certificate,(Exemption,you
should become subject to the Warken'Compenallon provkiora of the Labor TOT
CCN Code,you baba:forthwith comply with such provisions orthk permit shall be BUILDING
W j deemed rooked.
FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL C Hurebyaffirm that there b a combruction lending agency for the perform ELECTRIC FEE
Z anrn of the workfor which this permit k Wued tSm 3097,Civ.C.) T L:
0 O Lendees Name PLUMBING FEE r
IL h Lender.Addrcss QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Imnifythatlhavereadthisapplicatlonandetatethattheaboveinformatian
1 Is cortnd.Iagmbtomply with aB cityand muntyordinanresandkatelawe PERMIT ISSUANCE FEES PAID:
} misting to Wilding comtreMon,and hereby authorise rcpmentativas o(this '
F N city to eruerupon the above-mentioned property for Inspection pu rposee. ALTER OR ADDTO MECH.
? (We)agree to save,Indemnify and keep harWeu the City of Cupertino Date Reeei til
V against liabilities,pdgments, rte and apenseewhlcheraylnanywayaccrm AIR HANDLING UNIT(TO 10,000 CPM) SUBTOTAL:
agalutsald tyinconeequ o(Ih gra gdthiapermm.
g-LJ_q AIRHANDLINGUNR(OVER10,000CFM) CONSTRUCTION TAX
'igmture of Appllant/Contractor Data EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WTI)the applicant or future building occupant store or handle hazardous HEATING UNIT(10 103,000 BTU) Date Rec I
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the 09
Health and Safety Cade Sedion 25532(a)1 HEATING UNIT(OVER 100,000 BTI)) TO
RYea M No
311 the applicant or future Wilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) L4 ISSUANCE DATE
which co t havbdous air contamlrunta as defined by the Bay Area Air
Quality Management Distrid9 BOILER-COMP OHPOR 100,000 BTU) p
Y:s oo No
4 A
have BOILER.COMP(OVER100,000BN)
the California Health k Safety Code,Sections 25505,25533 and 25534.I (� Q 9
understand that 11 the building does not currently have a tenant,that it la;my NEW RESIDENTIAL MECH. SQ.FT ' AUCS 1992
responsibility to notify the occupant of the requirements which=at be met yJ
prior to Wuanco ofa Certificate of Occupancy.
CII Y �rcnunv
Owner or autumixed agent Date ISSUED BY
T024
OFFICE COPY