23653 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Address,
23653
nen ame: one: APPUCATION SUBMrrA[=
• — / f ;t CITY OF CUPERTINO-BUILDING DIVISION
C near'•N•^e: Pb- y�LIc.No: APPLICATION /PERMIT s—t�
`^-• �� • 3/7tiZ Z BUILDINGELECTRICALPLUMBINC-MECHANICAL CATEGORY CON�RO1,
rchltect/Engineer. Lie.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERNITISSUANCE ❑ ❑ ❑
LICENSED I am CONTR under rDECLA RATION
I herebyScctio 7OOO) fDiviscensedunderprovland Pi-cions of Cssiong9de,and nc- APPUANCESRESIDENTIAL JOB Dh8clul C(oN
inonce is inlon 7000)onDlvfect. fthe Bumnessand ProfeWona Code,end my
license Is In (o and effect PANELS
License Cla Lie.p �i �' L • ' �QI�\ 6 ,�•+ K
Date�• Contractor a`�� MV. eO
ARCHITE SDE LA ATION XII-1000 AMPS �'►/
q�q�ua ox O T ersland my plars sha8 be used as public records. OVER IWO AMPS SQ.FT.FLOO � � S/SQ.Fr.
hi
SIGNSELECTRICAL
A
L2 E
D IN
sed Professional
OWNER•BULDER DECLARATION
hatlam License the SPFGIALCERCUIT/MLSC
following ..:(Sento7 31,5,B aheadand Prafical.oe AnydttyorOp " ntyhickre aperttomtmalterpme=rhh, r r TEMP.METER POLE INSI.ppp anystm mpdartoiaanceabmquialiantfwettPOWERDEVICES
Ole a signed statement that he Is licensed pursuant to the prayidbrsof the
Contractor's License Taw(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC DAT
��0� slon3o(theBuslnessandProfessbruCode)orthathebexempttherefromand N /
the basis for the alleged exemption. Any violation of Section 70715 by any a
m
GX applicant for a permit subjectethe applicant to a civil penalty of out ore than OUTLEI"'SWITCI ff_SF7XI'URFS
five hundred dollars(¢S00).
�n
FIT,as owner of the pmperty,or my employees with wages as their sNEW RESIDENTIAL ELECTR ole SQ'F'• ~STORIES TYPE CONSTRUCTION
compensation,will do the work and the structure isnot Intended or offered for
p sal•(Sec.7044,Business and Professions Cale:The Contractors License Law
$ doesnotipply Loan owner of property who builds or improves thereon,and OCC.CROUP RES.UNITS
whodoeesuchworkhimself orthrough hisownemployees,provided thatauch
Improvements are not intended or offered for sale.If,however,the building or TOTAL:
improvement Issold wlthinaneyearofcomplelbn,the owner-budderwlli have
tl�urden of proving that M did not build or improve for purpose ofsale.). QTY, PLUMBINGPERMIT FEE RD TpNE nPN
"L as owner of the property,am exclusively=trading with licensed pER,�lIT ISSUANCE
contractors to construct the project(Sec 7014,Business and Professore,Code:
The Contractors License Law does^at apply to an owner of property who ALTER-DRAIN&VENT-WATER IFN
Wilds or Improves thereon,and who centrams for much ptojeM with e
Tefien.)Bmnsed pursuant to the ContnRare License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
yl am exempt under Sec B&P C for this resaon
OUTSIDE FEES
Owner Data DRAINS FLOOR ROOF,AREA,COND. SANITARY - Y N
• WOR KMAN COMPENSATION DECLARATION RECEIPTIf
�I hereby affirm that I have a certificate of consent to self-Insure,or a FIXTURES PER TRAP SCHOOL TAX Y N
rtlflrtteof Workms'Compemationlmunncaaae di(kdmpythemo((Sec. RECFExtN
3800,1.bC.) GAS F.A.SYSTEM-1 INCA OUTLETS PARK ITE Y N
Policy p RECEIPT X
Com en GAS EA.SYSTEM-OVER4(EA)
[� Y BUILDING DIVISION FEES
Camfied copy is herebyfurnished.city GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
CedlOed ropy V filed with the city inspection division. /
CERTIFICATE OF IXEMPFION FROM WORKERS' GREASE TRAP PAID _
COMPENSATION INSURANCE SEWER-SANITARY-STbRM EA.X1081'. Dalt'. Remi t#
(Thissectlon need not W completed I(the permit la forone hundred dollars
(5100)or
Imdity thaytha MWATER HEATER W/VENT/ELECTR ENERGYFEE Y N
t the performance owork ork for which this permit le blued, —
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation laws of Call(or ea.Date PAID
O Z Applicant
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB._SQ.FF. DatC Recei t#
should become sub)cd to the Workers'Comperaalion provisions of the Labor TOTAL:
V9 Code,you must fan hwith comply wlthsuch provlaiare or this permit shall be
j deemed revoked. _ I NG •
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby of@m that there Is a construction lending agency forthe perform TOTAL:
TRIC FEE
Z anm elite work(orwhichlhla permit bbmted(Sec.3097,CIv.C.) TOTAL:
U O iandersName PLUMBING FEE
LL H Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE r
O W Imdifythatl have read this applicatlonand nate thattheabove Information
0. bmriect.l agreeto comply with all city and county ordinances and mate laws PERMITISSUANCE 1 """ FEES PAID: ,
} relating to building conswRlan,a hereby uthodze representatives of this;(_ Z city taenterupon the above- nil ed pro rty for fix in purposes. LTER OR ADD TO MECH. l
V _ (We)agre o save,Inde I(4, d kae harmless the City of Cupedlno DRRC Reeel t#
against llabll 0,F' rad ex seawhlcheraylna^ywayaccrue AIR HANDLING UNIT ITO to,"CFM) SUBTOTAL,
again aid Ity In cons en the gr ting of this permit.
y �Z AIR HANDLING UNIT(OVER 10,000 CIM) CONSTRUCTION TAX
of Apptce /Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
1-1 Willthe applicant or futurebuildleg occupant stoic or handle hazardous HEATING UMT(TO ID0,=BTU) Date R2CC1 t#
material as dented by the Cupedlno Municipal Code Chapter 9.1$and the -
I lealth and Safety Cade Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL
I�Yea M No
Ilitheappilnntorfuw.buildingocmpantuseequlpment m crevice• VENITLA DON FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP OTB'OR 100,000 BTU) P A 9 pa
4 a es Q No V
h ve miulthchaz us naterialsrequimmnlaunderChapter6.95of BOILER-COMP(OVER 100,000 BTU)
the CaIfornla Health&Safety Code,Sections 25505,25533 and 25534.I {IRQV ax ���
and crum oil that if the Wilding does not currently have a tenant.that it is my NEW RFSTDENTIAL MECH. SQ.Fr erlMe
respmuibility to nod ify the.=part of the requirements which must be met J
prior to issuance of a Certificate of Occupancy. Y Uh
VUrcfT 1 uvV
Owner or authorized agent Data ISSUED BY:
lOT
OFFICE COPY