23130 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prom Identification ' PERMIT NO.
Building Address: QS , . 23130
0.r.Name: one:
CSD(-f-. (�Lt�axi f3.�3—bs3,2, CITY OF CUPERTINO-BUILDING DIVISION
c�rattura .nr: V Lm.No: APPLICATION /PERMIT
BUILDINGELEC'IRICA4PLUMBINGMECHAMCAL CATEGORY CONTal
Architm giber. Lie.No-
QTY
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add.. PERMATISSUANCE, MIM
LICENSED CONTRACTOR'S DECLARATION
thereby affirn lhatlam lkmaed under prwbione o(Chapter9(cormnen APPLIANCFARESU L JOB DESCRB'TION
Ingwith Se ion7000)of DiWsion3ofthe Bupnemand PmfemionsCode,mdm
license Is Infull force and Affect. PANES
DLicense Clam LIe.a ly
Date Contractor
ARCHITECTS DECLARATION 201-1 PS
aZI understand my plans shall be used m public records. OV .AMP$ ^ QFQ.Fir ARE
Op 5/SQ.Ff.�
E Licensed Professional SELECTRICAL ` "6� 1.3
<< OWNER-BUILDER DECLARATION ` ss�� y,l
.Z� Ihereby afflrmthat I am exempt from the Contractor's Licenselaw t e SPFGIA C I� LO ITL] ole) t-12
q❑❑ following reason.(Semon 703]5,Bualnem and ProlemionA Code:Any city or
FF' c^untywhkh rcqulresa permit to construct,alter,bnprove,dennlish,orrepalr TEMP. RPOLE]NST
qqM anyarudureprbrto Rsbwance,alsorequirestheappliamtforauchpemdtto pOWERD CES
6'�+y file a signed patenen[that he V Ikmued pursuant to the provL+loa of the
haw Contractor's License law(Chapter9(commenelogwlth Section 7000)of Divi- SWIMMN8 POOL ECTRIC
F OS alon3ofthe Busineasand Plfessi^aCade)orthathoiseumptthemfrom and VALUATION
yl the basis for the alleged exemption. Any violation of Section 7MI.5 by any
OS
applicant for.permit subjects the applicant to a civil penalty of not mom ban OUTLETSS CHFSFIXTURES
f h red ner of he pr. SQ
NEW RESIDENTIAL ELECTR
�n caner of oche work,and
he employees lit Withtended as fferedfoir sets STORIES TYPE CONS'IROCI'ION'
peas Mon,Business work.euslons Cdurcbn Contractors
License
A
O le(See to Businessand
property who
Wilds or improves
Lluae Law W
3$ dote not apply torn imserotpropertywho own employees,
improovidedreoryand OCC.GROIIP RFS.UNITS
EEEE whodoeaams such Are net mseldedmugh Msowtie.If,ho a;er,thedthalsoch —
ImprovementsarenmithindAeyearferedtorsale.theo veytilderwdI have T
Improvement V wldwithin oneycarofcompletlostheowner-bullderwlll have
theburdenof proving that he did not build or improve for purpose of sale.). Q , PLUMBING PERMIT FEE FLOODZONE TPN
0{as owner of the property,am exclusively contracting with licensed
contactants to construct the project(Sec 7044,Business and Professions Code: PERMIT ISSUANCE ^r
The Comeaaots License law does not apply to an owner of property who pLTFA-DRAIN k VFNr-WATER(EA) ^
builds or Improves thereon,and who contracts; for such p(ojects with a
op4actor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEF.SUMMARY
LJ I am exempt under Sec. B k P C for this meaaonOUTS I
Owner DRAINS FLOORR GOND. SANITARY Y N_
Date RECEIPT I
WORKMAN COMPENSATION DECLARATION
" ❑I hereby statim that I have a cerificua of consent to self-Insure,ora FI%%TURES-PER TRA]' SCItOOL FAX Y_ N
RECEIPT N
certNnteo(Work m'Compewadonlaumnm cracertified copythereo((Sec.
3800,Lab C.) CAS F.A.SY -1 INCA 0V17. S PARK PEE Y N
Policy 8 RECEPT 8
Com any GAS ER4(EA) BUILDING DIVISIONFITS
�CertiOed copy is bercbytumecity GREASEINDUSTRL INTERCEPTOR PLANC14ECK FEE O+
Certified copy V(fled with the city Inspection division. s
CERTIFICATE.OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE 1 OG
(Thissecilon need not be completed if the permit is for one hundred dollars SEWER"SANITARY-STORM F.A.202 ifDate Recei t#
(f10 lem
coulN.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y
I certifythat the performance of the work for which this Fourth bssu
perIssued,
I sha it not employ any person In any manner An as to become abject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date PA
O Z Applicant .
Z O
NOTICE TO APPLICANT:ILafter raking this Certificate of Exam ption,you NEWRESIDENTIALPLfs! SQ.IT. Date cel t#
I" should beeonc subject to the Workers'Compnaatl^n proWloa ofthe Labor TAG
N Cod,you at forthwith comply with such provlslore or this permit shall
> deemed revoked. N
CL G CONSTRUCTION LENDING AGENCY SEISMIC F
Ihercbyaffirm that there is a coataction lending agency for the perform- ELECTRIC E
Z stint of the work for which this permit issued(Sec.3097,Civ.C.)
V O Iender'a Nam^ PLUM I F-E
U. 1- Landers Address QTY. MECHANICAL PER FEE M A ]CAL E
O W (cert ify that have read this applicationand pate that theabove lnformatlon
U correct.l agree to comply with all dtyand county ordleanara and patelaws PERMIT ISSUANCE FEES PAI
T IL relating to building costrection,and hereby authorize representatives ofthis
I" N city to enter upon the above-nnntioad property for inspection purpose. ALTERORADDTOMECH.
Z (We)agree to save,Indemnify an d keep harmless the City of Cu Fortino Date ReceI t#
Against liabilities,Pdgments,cops a rd expenses which cosy In any way acute AIR HANDLING UNIT TO 10,000 CFM) SUBTOTAL:
ainst CI co equenceofthe gra tingolthlspertnit
a-e9 93 AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUC ONTA
Sigatu !Applicant/Contractor Date E%HAUSr HOOD(W/DUCT) CONSTRUCT] N TAX
HAZA R DOUS MATERIALS D CLOSURE �((J
Will the applicant or future building oecvpantstore or handle hazardous HFATINGUNIT(TOIDgODOBTU) Date RCe I t
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety Code Section 2SS32(a)7 HEATING UNIT(OVER 100,000 BTU)
RYes tj No
ill the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE REBID) ISSUANCM ATE
which cunt hazardous air contaminants as dell tied by the Bay Area Air
Quality Management District? BOILER-COMP PHP OR 100,0110 BTU) '
Yo n No B�
havfcmla teeth& tet mode, Salo rementsun3aChapter.1 u( BOR.HR-COMP(OVf7t 100,000 BTU)
the Cel and to Health A Safety Cods Settloa currently
h ve a tenant,and 75534.I
understand that if nthfy the onupant not erequir have which=at
It key NEW RESIDENTIAL MECFi. SQ.I•T. ����
responsibilitynto cenail(ytheocteof aftherequircmentswhichmustbemat prior to issuance ofaCertifkate of Occupancy. FEBD 1
M
Owner or authorlud agent Data
15SUI- BY;
OFFICE COPY