23588 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALLPOINT PEN ONLY
Buildingm
P 'ect Identification '+ PFRMTTNO.
BuOding Address: -
O53q - 23588
C �" S
• refs Name: one:
P11 11 CITY OF CUPERTINO-BUILDING DIVISION'. -
Cnn° rtee N Lie.N.: APPLICATION / PERMIT — --
11 Architect—�/Engineeen . Lie.N. 0f1ILDINGELECTRICALrLUM01NGMFGFUMCAL CA AY CONTROL X
QIY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMOTISSUANCE �° IC71 I`QII
LICENSED CONTR under provisions
Ihereby aB4mthu am Dtvisimsedundustrun Wonsof Cha)Rer9(mmmm APPEANCFSRESIDENTUL JOB DESCRIPTION
Banish Sectlon7000)o(Dlvielon3oflhe Buslreuand ProlnJoneCode,and my ,
license lCie NB force and dfed. PANELS
DateLi Clam Llcp
Dale - Contnrtor tIC�`tM` Vow
ARCHITECTS DECLARATION 200-IWDAMPS
ren Z 1 understand my plans shall be used as public records. OVER IOW AMPS SQ.FT.FLOOR AREA $/$Q.Fr.
❑O
Licensed Pr.feselolal - SIGNS ELECTRICAL .
6 w OWNER-BUILDER DECLARATION
G SPECULCIRCUIT/MLSC
7 p,. I hereby affirm that I am exempt from the Contractors Licenselaw for the '
O rs following ream.(Section 70315,Business and Professions Code:Any city or TEMP METER OR POLE INST. -
P county which requires a permittocorutmct,alter,Improve,deniollsh,or repair
.� anystructure priorto Its issuance,also requireslheapplinnt fonuch permlt to POWER DEVICES
Ble a signed statement that he is licensed pursuant to the provisions of the
�w� Contractors License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC -
k- s1..3.fth.0usinnaand ProfessionsCods)mthat he a,exempttherefromand VALUATION- _ 0 O D
O the basis for the alleged exemption. Any violation of Section 7031S by any OUTLETSSWHCHFSEXTUAFS
applicant fora permit subjectsthe applicant to a dv11 penalty of not more than
Q ❑❑❑���.��e yyynnndred dollars(g.S00). SQ,FT. STOWES TYPE CONSTRUCTION
u• NEW RESIDENTIAL ELFLTR
aownerll tatproperty,or my employees Inwithwages r their sole
C c &c.7044pereation,wllldothewormfr.Imk and the structures not Umnjmd(or -
5 0 ale(Sec.7044,to ainessendf property
Code:The or Improves
Weenie law
docs f$
who does
apply tornowner orp rough who Wilds
mpoyed,povided cotsuch OCC.GROUP RES UNITS
wprove ets amwork tinthimself dedorwgh hlsownemp,heave,er,the uildin or
improvement issold intendeeyearofcomplroffered sale.theowevep t1der ill have .TOT •�-
Improvement6soldwithin.neynaro(completion,lheowner-bu0derw111 have
1len of proving that hedid out build or Improve for purpose orale.). QTY; PLUMBING PERMIT FEE FLOOD ZONE APN
as PERMIT ISSUANCE owner of the property,am exclusively contracting wllh licensed
ore to construct the project(Sec.7044,Business and Professions Code: I
The Contractor's License law don no not apply to an owner of property who ALTER-DRAIN kVENT-WA1112(EA) sw
Wilds or Improves thereon, and who contracts,for such pRoject,with a FEE SUMMARY
cgg(�ctor(s)licensed.pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
IJ I am exempt under Sec. B k P C for this reamn '
Owner Uate /�.Ly DRAINS hi00R ROOF,AREA,COND. l �. SANITARY Y N
FEES
OMPIN IONDECLA I - RECEBTM `
P of
reby affirm that that I have a nrtiRnte of consent to sslf-insurs,or FIXTURES PER TRAP SCHOOL TAX Y_ N_
S
cenifimtoofworken'Compe.ti nireuranceoracertifL,dmpythereof(Sec. RECEIPTp
3800,Lab C.) GAEA.5YSTEM-1 INCAOUTLET5 PARK FIE Y N_
Pollry p - GAS EA.SYSTEM-OVER 4(PA) RECEIPT p -
Com any - B U I L DING DI VI SION FRES'
Certified copy le hereby Nrnle city GREASEANDUSML WASTE INTERCEPTOR PLANCHECK FEE '
Crallied copy is filedhere y hirele city inspection division. JVD
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID L•
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.2BIFT. Date Remi tat
Rhb section need nn W completed the permit 6Nr.ne hure
ndd dollars
(9100).rlsss3 WATER Ii EATER W/VENT/ELECTR ENERGY FEE Y N
I certify that In the perfnrmince.f the work forwhich this permit is hated, —
I shall not employ any person In any manner m as to become subject to the WATER 5Y5777d/TRFAI7NG
Worker'Compensation l wa.f California. Data PAID
C) Z Applleant NEWRESTDENTTALPLMB. SQFT. Date Recei tk
Z 'NOTICE TO APPLICANT:ILafter making this Certificate of Faempllon,you '
should become subject in the Workers'Compereation proelalone of the LaborCC 'TOTAL'
4A Code,you Mgt forthwith comply with such provisions or this permit shall be BUILDING •E
W > - deemed revoked.
CL
3 - CONSTRUCTION LENDING AGENCY SEISMIC FEE cih
I hereby arfirmthal there is a mastruction lending agency for the perform- ELECTRIC
L) Z ance ofthe.rkf.rwhichthrspermltisWued(Sec.W97,Civ.C.) T
U O I.noses Names PLUMBING FEE
LL F Isndere Addrtss QTY. MECHANICAL PERMIT- FEEMECHANICAL FEE
O W I cenlrythatl have read thlsappllcationand slatethattheabovainrormmion -
Ismrred.Iagmeto comply'wlth all city and countyordlnancesand stale laws PERMI'TISSUANCE FEES PAID:
} U) relating tobulldingnslruction,and herebyauthmire reprenta
setivesofthb
H 2 mcity to enter upon the above,mentloned property for lrapection purposes. ALTER OR ADD TO MFCH. Date Reeel IH
_ (We)agree to save,Indemnify an d keep harmless the City of Cupertino - F
a gal rut llabilltles,judgments,matsand expenses which nay in anyway accrue AIRHANDLINGUNITQOI0,000CFM) SUBTOTAL:
agaln<t said City In m..equenn th antlegofthb It
.. AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
.Ig !,m.f Applran/Cont, or Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: '
I. HAZARDOUS MATERIALS DISCLOSURE
Illthe applicant.,future Wilding oocvpant store or handle hazard... HEATING UNIT(10100,000 BTU) Date Receipt
r oarrial as defined by the Cupertino Municipal Code,Chapter 9.1Z and the
Ilealthand Safety C.de Sedi..25532(a)7 !TEASING UNIT(OVER 100,000 BTU - TOTA
❑tYea No '
Willtheeppliont or No buRding ompanl use equiprrcnt or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which doll hazardous air contaminants as defined by the Bay Area Air - - Pi A 10 I
Quality Management DlsMNY. P BOILER-COMP pId'DR 1W,IXq BTU V
4 Yes No
)witomia lhehrm o"C.dr,S ri.m2rnenleunder Chapter 6.95 of BORER-COMP(OVER]W,000 BTU) PR 28 1992
the Glifornlahealth building
a tenant,
that. 1 d�rJ�
resprstandthat lithe notify
thldingdoee of
te correctlyhavewhich that 111 my NEW RESIDENTIAL M4ECli. EQ.T•7 .
( rssp.to Issuanclity of aCeheoate Of Ocr panty.requirements which must be rrM CI7Ir ser `u�'
prior to Issuance ofaCertlfkate ofOmpanry. '` 4p_y�/� LirYyIIVV
Ownermaulhorized agent Date ISSUED _ e- .^.
TOTAL:
OFFICE COPY