23321 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Address: 4 23321
028 L4.rr L•
nen ante: one' Al'I'LVLA IIQN bUbsitf IAL D=A
e>Be LLQ 7 3 — I ZA I CITY OF CUPERTINO-BUILDING DIVISION .�� Q
C(y/nerattor's Na Lae.No: APPLICATION / PERMIT Q
ISO JK. OOLS 'sJ G Z7 S S L' G'S3 BUILDINGELECTRICALML BINGMECHAMCAL CATEGORY C
Architect/Engineer. Llc.Na
A1Ll.Ls 6 O QTy ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: WU /}•rOxs 4xN PERMITISSUANCE � ElLICENSED CONTRACTOR'SR
DECLAATION
I hereby affirm that l am licensed under provisions of Chapter 9(drourvenc, APPLIANCESRESIDENIIAL JOB DESC ON
ingwith Soction 7000)of DiAslon3ofthe Buslnessand PmfesslonsC c,and my
license Ism fullforce d effect. �T QQ PANELS
License. ss Lie. Z/L?OS L 1
Date I ContraUP 102OU ANTS
ARCHITECTS DEC RATION 201-1000 AMPS
reZ Lunde tandmyplamshaRbeusdapublicremrdw OVER 1000 AMPS �SQ �R I 5/�.FT.
OO Ea Licensed Professional SIGNS ELECTRICAL
<¢ OWNER-BUILDER DECLARATION Q�
�n SPECIALCE2CUIT/MLSC r
owingrIhcrcbyasovnthat I am ction7xemptfroessa Contractor's License law(ort he
&R
following reason.(Section 7001.5,Business and Professions Code:Any dry orTEMP,METER OR POLE INST.
cy
county which requires a pernottocorutrualter,improve,demolish,orrepair
1m anystructum priorto Its Issuance,also requlresthe applicant forsuch permit toPOWER DEVICES
a file a signed statement that he b licensed pursues to the provisions of the
�3_G Contractor's LacenueLaw(Chzpter9(comm,ndngwith Section7000)ofMot- `5 BWR MNG POOL ELECTRIC �_ VALUA
O Mon 3 ofthe Business and Professlots b Code)or that he exempttherefrom and a/7 the bsab for the alleged exemption. Any violation of Sedlo70315 by any OUTLETSSW[TCHFSFlXNRES
OA applicant fora pemdt subjectstheapp'cant toadvll penalty dna morethan
R five hundred dollars(Sm. NEW RESIDENTIAL ELECIR SQF7.
�. ❑I,as owner of the property,or my employees with wages as their sole STORIES TYPE CONSTRUCTION
C compensation,wRl do the work and the structure b not Intended or offend for
r 'S
sale(Sec.70K Business a nd Professions Code:The Contractor's License Law
does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RES.UNITS
who doessuch work himself orthruugh his own employees,provided that such
improvements are not Intended oroffered for sale.If,however,thebuilding or T
improvement issold within oneyearofcomplalon,the o vect,bullderwll)have
t4e.kmoden of proving that he did not build or Improve for purpose of ask.). QTY, PLUMBING PERMIT FEE FIAOO ZONE APN
U 1,as owner of the property,am exclusively contracting with licensed 171SSUANCE
is roetractom to construct the project(Sec.7004,Business and Professions Code:
The Contractor's License Law don not apply to an owner d property who ALTER-DRAIN VENT-WATER(EA)
Wilda or improves thereon, and who contracts for such pW is with a
dpiI.aor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
UI am exempt under Sec - B&P C for this reasonOUTS1 DE FEES
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N_
Owner Date RECERxT p
WORM
KAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N
E31 hereby affirm that I have a certlRate of consent to self-insure,ora RECEIPT p
3 3800,Lab
o(Workers'Compewallon Insurance or a rertlBd copy thereof(Sec. GAS FA.SYSTEM-1 INCA OUTLETS �. PARK FEE Y N
Policy M ftECEPT#GAS EA.SYSTEM-OVER 4(EA)
Cram anyML1C .O A)TiN LN /.'C_. BUILDING OI VISION Fr.ES
Ccr(Bied copy Is hereby furnished. GREASEANDUSTRL WASTE INTERCEPTOR PLANCI'IECK FEE / �
Comfi d ropy b filed with the city iwpectlon division. /_n
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAI? ��ii//
COMPENSATION INSURANCESEWERSANITARYSTORM EA.200F1'. C Recei IN
Rhis sedaon red na We complied If the permit b furore hundred dollam
($100)orlem.) WATER HEATER W/VFXT/ELECTR EN' FEE Y_ N_
I certify that in the pedormanceof the work forwhlch this permit is Iwnd,
I shall not employ any person In any tanner so as to become subject to the WAT R SYSTEM/TRFATING .
Workers Compensation Laws of Califomb.Date PAID
-
0 Z Applicant NEW RE IDFJ II L[LMB. SQFI'. Date Remi tit
Z O NOTICE TO APPLICANT:IL after raking this Certifiateof Exemption,you
should become subject to the Workers'Compensation provisions ofthe Labor TOTAL: _
F N Code,you most forthwith comply with such provisions orthb permit shell be BUILDING
j revoked..tl revok .
CONSTRUCTION LENDING AGENCY SEISMIC FEE
J IL I hereby affirmthat there as a construction lending agency for the perform T T ELECTRIC FEE
7 Z ance ofthe work for yhlclxthia permit Is issued fSec.3097,Civ.C.)
U O Ierder'.Name PLUMBING FEE
F- Iander'a Address QTY. MECHANICAL PERMIT FEE
0 W Icedifythat l hay rodt bapplia&mad state that theabove information MECHANICAL FEE
1 Is correct.I agree to complywith all cityand county ordinances and state laws PERMIT ISSUANCE FEES PAID:
T relating to Wilding consuuttlon,and hereby authorlu reposentatives.fthb
I— Z city to enter upon the above-mentiond property for inspection purposes. ALTER ORADDTO MECH.
(We)agree t ve,indemnify an d koep harmless the City of Cupertino Date ReceiplN
V agaaretllablRtle ments,costsandexpenses whkh may In anyway accrue AIR HANDLING UMI(TO 10,000 CFM) SUBTOTAL:
Ci c
sequence of the granting of this pe t.
AIR HANDLING UNIT(OVER 10,000 CRM) CONSTRUCTION TAX
L_ CONSTRUCTION TAX PAID:
6&1 PPI t ontrador Date IX}LIUST HOOD(W/DLK7T
RDOUS MATERIALS DISCIASU Ui
Wlllthea Ilan rfuture building occu ant store or handle haeardoua HEATING UMT(T0100,000 BTU)
PP B P Date Recei tN
Iealt material as defend by ode
Cupertino Municipal Code Chapter 9.12,and the
ieslth and Safety Cde Section 25532(a)? HEATING UNIT(OVER 100,00(i BTU) TOT
❑ Yo M No
Will theappliant or town,building occupant use equipment.,devices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which emit hazardous air comandants as defend by the Bay Area Air 11�� pp
Quality Management District? BOILER-COMP OHPOR 100,0(D BTU) P A I D
4Yes FF—II No
have read the hazar7i. a materials rcqulmorents under Chapter 6.95 of BOILER-COMP(OVER100,000 BN) MAR
n
the California Health&Safety Code,Sections 25505,23533 and 25530.1 MAR 1992
s undemta that lithe Wilding does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. 5Q.FT
rap. a ty to na' the occupant of the requirements which most be met
prio sanertlRcateofoccupancy. I
CITY Uf UUFCfTIII'l.
z V,8 (��(/��
author[ t ate TOTAL: ISSUED'y�
OFFICE COPY