23369APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Address Sri FL
2 rz�D
PERMITNO.
23369
wnere came: one:
CITY OF CUPERTIN0.BUILDING DIVISION
APPLICATION / PERMIT
�J
Contra &.N. Lic No:
CATEGORY
CONTROLX
r ✓'
BUILDINGELFCTRICALPLUMBINGMECHAMCAL
Archlted/Engineer. Lk. Nm
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Add"': r.7 /
UCF.NSEDCON CfOR'SDECLARATION
[hereby affrmthat l am licensed under provisions or Chapter 9(commmc
Ingwh [.full 7000)of Dlvhlon3otthe Buslnusand Pro(eul.naCade,and my
se
licenIs In 5rfi 7000) and dfM.
PERMITISSUANCE
J
APPUANCES.RESIDENrTIAL
JOB DESCRIPTION
PANELS
Limnse Cla® Lich
Date Contractor
201-I ODO AMPS
ARCHITECTS DECLARATION
I understand my plats shag be used as, public records.
OVER 1000 AMPS
SQ. Ff. FLOOR AREA S/SQ. FT.
SIGNSELECTRICALL
Licensed Profeulunsl
CG D 'N
OWNER -BUILDER DECLARATION
I hereby affirm that l am exempt from the Contractor's Lirenw IA.forihe
following me..(Secilon 7071.5, Business and Profession. Code: Any city or
county which requlresa permit reconstruct, alter, Improve, demolish, orrepalr
S1eF.C1AL CIRCNT/MLSC
,v
P E R
TEMP. OR POLE [NST.
anystrochme prior to its Issuance, also requires the applicant for such permit to
file a signed statement that he la licensed pursuant to the provisions of the
Contractor's License Lsw(Chapter 9(commencing with Section 700D) of Divi-
skm3 of the Busineuand PredestinedCode)arthet he h exempt therefrom and
the bush for the alleged exemption. Any violation of Section 70313 by any
applicant for a permit subjectetheappikant to a civil penalty d ner more than
POWER DEVICES
SWAIMINC POOL ELECTRIC
OUTLETSSWITCHFSI•T%TURES
VALUA
NEW RESIDENTIAL ELECTR _SOFT.
five hundred dollars ($SM.
n I, as owner of the property, or my employees with wager. as their sole
STOW ES
I YPE CONS[RIrCTION
compensation, wllldothe wok andthe structure is not Intended or offered for
sale (See 7041, B..ionsa and Professions Code: The Contractor. License Law
does not apply to an owner of property who buids or lmpmms thereon,and
who does such work himself or through his own employee., provided that such
OCC.GROUP
RIS. AMTS
Improvements are nd Intended oroffered forule. IL however, thebuilding or
improvement heold within one yearofcompletion, the awnar-bufid erwill have
U�Jguden of proving that he did not build or Improve to purpose of uleJ,
Lj L as owner of the property, am exclusively mntrading with Iimnsed
contractors to conmmct the pmjed(Sec. 7044, Business and Prdemlort4Code:
TOTAL:
QTY. PLUMBING PERMIT M.
PERMITISSUANCE —r
FLOODZONE
APN
The Contrectors License Law does not apply to an owner d property who
Wilds or Improves thereon, and who contracts for such pt,o�ecta with a
cgBTpetor(s) Bernard pursuant to the Cmmear. Llanse Law.
l_I I am exempt under See. B k P C for thin reason
ALTER -DRAIN k VENT- WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, GOND.
FDCTURF.S PER TRAP
SANITARY Y N
RECEIPT X_
Owner Date
WORKMAN COMPENSATION DECLARATION
[31 hereby affirm that I have a artl(lote of consent to self-Inwre,
SCHOOL TAX Y NRECEIPT
car a
3800, IbC.) rken'Compensatlonlnsuranm 0racertifled mpythereof(Sec,
3800, LabCJ
X
GAS EA. SYSTEM -1 INCA OUTLETS
PARK FEJT Y N
Policy p
RECEIPT X
GAS EA. SYSTEM-OVER4(EA)
Cam an Y
BUILDING DIVISION FEES
Cerdfi)d copy is hereby tthe city hhci Inspection didivision.GREASE/INDUSTRL
�Certlfied copy h filed with the
WASTE INTERCEPTOR
PLANCHECK FEE
GREASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Rhl.sedlon need not becamplded If the permlt h for ori) hundred dollars
PAID
Date Remi t#
SEWER-SANHARY-STORM EA 2WFr
(SI D().rle.s.)
Illnify thatoy to anyhe ersonI anytnumnerhe work sores tobecoseermlthho thead,
I shall rad employ any Tenon In any manner at a to become subject to the
a'Compensallon Laws of California.California.WATER
la. Date
WATER HEATER W/VENT/ELECTR
ENERGY FEE YN —
PAID
SYSIRM/TREATING
Applicant
Applicant
NOTICE ca APPLICANT: a after making thinsationCertificate of Exemption,you
should become subject t. the Workers' Compensation provhiors of the Labor
deemed d.orevookeforthwith comply with auchpavblors orthb permit shall be
Date Recd t#
NEW RESIDENTIAL PLMB. SQFT.
TOTAL:
BUILDING FEE
T
SEISMIC FEE
ELECTRIC FEE
CONSTRUCTION LENDING AGENCY
I hereby afflrmthat there is a construction lending agency for the perform
ance of the work for which this permit Is listed (Sec. 3097, Cly. C.)
Lender's Name
Lenaer.Addie..
I and Bt that I have read thin appucatlon and state that theabove Information
qrY. MECHANICAL PERMIT FEE
PLUMBING PEE
MECHANICAL FEE
FEES PAID:
iscorret. I agreeto comply with all city and county ordinances and state law.
PERMITISSUANCE
relating to building construction, and hereby authorize representatives of this
city to enter upon the above-mentioned property for inspection purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
agalnsliabilities,' dgments, cams and expense whiheraylnanywayacenue
again aaly mn.crye or the gv t or ml
ALTERORADDTOMECH.
AIR HANDLING UNIT CFO 10,000CFM)
Date Receipt#
SUBTOTAL:
AIR IuhroLINc uNI (ovER lo,000crh)
CONSTRUCTION TAX
Igw .o Applicant/CEedmctor Data
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUSMATE SDISCLOSURE
HEATING UNIT LED 100,000 BM
Wllltheappllcant or future building occupant store or handle hazardous
material as defined by the Cupertino Munidpal Code, Chapter 9.12, and the
Health and Safety Code Section25532(a)P
❑ YeaM No
Date RCeei !#
HEATING UNIT (OVER 100,000 BTU)
TOTA
;-�
VENTILATION FAN( SINGLE REBID)
ISSUANCE DATE
; qq
A I D
AR
M-'• +5
Will the applicant or future building ocmpant use equlpment.,device,
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management Dletrid7
4Yean N0
haveread the hax.yusmaterials requirements under Chapter 6.95of
the California Health k Safety Code, SoCkma, 25505, 25533 and 25534. 1
BOILER -COMP OHP OR 100,0(D BTI[)
BOILER -COMP (OVER 10D,OW BTU)
NEW RESIDENTIAL MECH. SQ.FT
understand that if the building does not ru enlly have a tenant, that it is my
responsibility to notify the occupant of the requirements which must be met
rlo anreof dificatc of avpa
f.51
co [✓r ]AQsA
9
—
ISSUEDBY: Kl ,
Owner or authorized agent Date
TOTAL
OFFICE COPY