23133 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Build log Add mm: 23133
TZ71 cT(e, — (? D CITY OF CUPERTINO-BUILDING DIVISION
c°nratto eNa Lfc.N.: APPLICATION / PERMIT
Lie.Architect/Engineer. �L BOLDING-ELECTRICALPLI)MBING-MEUTAMCAL CATEGORY CONTROL#
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add.. PERhITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I Mreby e(flrm that l am hem"under provisions of Chapter9(commenc, APPLIANCES.RESLISNTIAL JOB DESCRIPTION
IngwithSe ion9000)of DtWgon3ofthe Buaineuand Profs onsCodgand my 1
It...Is in NI ome and effect. PANELS c� a6��rYryy�k
LlcenI'C am LlepM
Dale 2-�7, Cantnctar
ARCHITECT ECLARATID 201-1000 zfi V A.1
DCO f understand my platuehall be used as public record.. AA LSQ�I',E7,�R ARN S/SQ.FT.
do(/ Llcenaed Professional NS ELEC CA 1{E�w DD ' Pons'
7�-< y OWNER-BUILDER DECLARATION SPECIAL CIRC /MISC P u E R
I here's affirm that l am exemptfrom the Contractor's License Law for lh LIM
o following reason.(Section 7QI1.5,Business and lsroleubne Code:An ci 0
OZ`ff..ggqq Y ty TEMP.METLRORPOLEINST.
P45°� countywhichrequbesapermittoconstroa,alfer,lmpmvgdemolbh,ormpalrMTE
anystmclumpr rtolbiswance,aborequreslheappBcantforsuchpermifto POWER DEVICES �r
file a signed statement that he is licensed pursuant to the provbioru of the
w Contractor's License Law(Chapter 9(commencing with Semon 7000)of Divi- SWIMhINC POOL ELECTRIC
�O sion3 oflhe Business and ProfessionsCode)orthat he b exempttherefromand -VALUATION
......773777 the basis for the alleged eaemptbn. Any violation of Section 70315 by any OUTLETSSWITCfffSHXTURES 20�Oeo
0 applicant for a permit subjects the applicant to a civil penalty of not mmethan
flvve,hundmd dollars(¢500).
1 1 NEW RESIDENTIAL ELECTR SQ.FT.
�n a as owner of the property,or my employees with wages r thele sole STOW ES TYPE CONSTRUCTION
compC .1.Gae tion,700 will do B..buhe was);,Profo the mstructure The ot Cmdrut.dor offeredLaw
5 0 ale(Sec apply
to an ow andf progeny Code:The Contractors the mue Law
3� and
whoddoes ot apply torkhinrmpropgh hisobuilds nemorimpmwmlhemwRuch OCC.GROUP RTS UMTS
C wprovemoe uch am not maelfedcroffemdowne.If,ho ee,provided that such
Improvementsarcnotintended earofco tweak.ILhowevcg Uder iltha°r TOT
Improvement bsold within one yeamfcomplmlon,the mvner-bullderwlil have
t"Acien of proving that hedidnmbuOdorlmproveforpurpoaeofule.). QTY. PLUMBING PERMIT FEEFLOOO7ONE APN
(_f L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE �r
contractor to construct the project(Sec.7066,Businessend Professi°m Code:
The Contractor's License law does nm apply to an owner of property who - ALTER-DRAIN&VENT-WATER(EA)
Wild,or Improves thereon,and who contracts for each pVocts with e
mum BACK FLOW PROTECT.DEVICE ctm(s)firenaed pumrenl to the Contranota License Law. FEE SUMMARY
Lem exempt under Sec. B&P C for this mu
DRAINS.FLOOR ROOF,AREA,CONTI. SANITARY Y N�
Owner Date RECmPT Y
WORK MAN COMP ENSATION DECLARATION I FIXTURES PER TRAP xse SCHOOL TAX Y N
❑I hereby affirm that I have a lmuran of concent to self-insure,ora RECEIPT Y
3800,ce4ifiab of Workers'Compensatlonlnsurance ora ceYl(led ropythereof(Sec. GAS EA.SYSTE)d-I INC.60I17LEf5 PARK FEE Y N
Polis # C.)
P°Ilry Y RECEIPT Y
Com any GAS EA.9YSTEM-OVER4(FA) BUILDING OI VISION FEES
❑Cemtifled copy is hercbytumty GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
d.
�rtifled copy b Ned with theecity inspection division,
CERTIRCATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SAMTARY-STORM EA.20MT. Date RC0.'I t#139.55
(T).r l..on m.d not be completed lithe permit b(Drone hundred dollars
(81001 oily that
WATER HEATER W/VENT/ELDCTR ENERGY FEE Y N
(certify that In the performance olthe work forwhlch this pemdt is blued,
I Whale not employ any perwn In any manner w u to become wbjett to the WATER SYSTEM/TREATING .('
Workers Compensation laws of Gll(ornla.Date PAID 7
O Z NOTICE NEW RESIDENTIAL PLMB. SQFT. ate Recei tN
Z 0 NOApplicant AI'PLICANT:IL after nuking lie Certiflafe of Exemption,you
should become subject to the Workers'Compensation provbionsofthe Labor TOTAL:
f/2 Code,you moat forthwith comply with such provisions 9rthb permit shall be +
LU j deemed revoked. BUIL12ING FEE /�
CONSTRUCTION LENDING AGENCY
p SEISMIC FEE a
CL IherebyaNrmthattherc isamnatmetion lendingagency forthe perform TOA �. ELECTRIC FEE —
ra
Z anmofthework forwhich this permit is Issued(See.3097,CIv.C.)
f.1 O Lander'.Name PLUMBING FEE �.
LL F Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icertlfythafl have read thbapplicationand statethatthe above information �.
UJ Iecormd lag reo to comply with all city and county ordinances and Yate laws PERMIT ISSUANCE FEES PAID:
relating t°building construction,and hereby aufhorlu representatives offhis
N
U) city to enter upon the above-mentimed property for Inspection purposes. ALTER OR ADD TO MECH.
— (W a c ave,IMemmty an d keep harmless the City of Cupertino Date Receiptlt
agaWt illtht",ydgmenb,coYeand expenses which rtuy in anywaya a AIR HANDLING UNIT FLOW CFM) SUBTOTAL:
agalns City In conaequenceofthe granting a thls pe.it.
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Slg a pliant/Contnnor Data I EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE LL
Will the applicant or future building occupant store or handle hazardous HEATING UMT(TO100,00013171.1) Date Recei tW
material as defined by the Cpertlno Municipal Code,Chapter 9.12,and the
Health and Safety Code.Sa'Im 255324)? HEATING UNIT(OVER 100,000 BTLI) TOTAL:
❑Yes No
Will the applicant orfuture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants u defined by the Bay Arca At,
Quality Management Dut' 7 BOILER-COMPOhR'OR100,000BTU)
Yes No
, ..it ave read the haze ous materials requirements underChapter6.95 of )TOILER-COMP(OVE4100,000 BTU) p 1 D
..it
California Health&Safety Code,Senims 25505,25533 and 25534.1 65
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ-p
respo Ib BY tonotify the accupant of the requlmmenls which at be reel a/)All
.s
prim( ance of a Certificate of Oocopanrykin
. d '911
Owitrateata
o authorized age t� Data D7O ISSUED BY: — si'tt�V'aw INd
OFFICE COPY