23338APPLICANT TO FILL IN INFORMATIONVITHIN RED LINES ' USE BALL POINT PEN ONLY
Building Project Identification -
ndngZ2y3z ��,�.u5 of e+: .,
PERMIT NO.
.' 23338
caner. sate: one:
APPLICA I LUN IUBMI I I A
Q j .255-18,*
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDINGELECTRICALPLUMBING-MECHANICAL
range's Na me: Lie. No:
r D
CATEGORY
CONTROL If
Architect/Engineer: Lie No:
QTY ELECTRIC PERMIT FEE
- BUILDING PERMIT INFO
- q
Address: 991Z
El
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affrmthat lam licensed under pravidonsof Chapter9(mmmenc
cdJcn 0(0)of Dieffect ofthe Buslnessand ProlesdonsCode,andm
Irersei
APPLIANCESRFSIDENI'IAL
JOB DESCRIPTION
license h taf.11 (Dean effect `
PANELS
✓4 „�`
,
Date Contractor
IM IQ 2DOAMPS
201-1000 AMPS
ARCHITECTS DECLARATION
I understand my plans shall be used as public records.
OVER IOW AMPS
SQ. FT. FLOOR AREA . $/9Q. FT.
Licensed Professional
SIGNS ELECTRICAL
A L E D '
OWNER -BUILDER DECLARATION
I hereby alarm that l am exempt fromthe law (ce the
SPECIALCI(CUIT/MISC r
'
`, U T E
TEM P.METERORPOLEINST.
d Prefctor'n a Ccaae
f ntywhi arequimape7tS, BusMdalt Pimpmnse=lehnydpor
cauntywhich requlmapemdt t°mruhud, alter,Improve, demoWh,orrcpsir
� /����
anyevucture price to Its ieauance,ahorequiresthe applicantfor such pemdtto
file a signed atatemeat that he is licensed pursuant to the pnevlalow of the
Contractors License Law (Chapmr9(commencing with Section 7000)of Divi-
slon3 ofthe Business and Professions Code) orthat he is exempt therefromand
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant for. perounubjects the appllcantto a civil penalty of not morethan
ndred dollars ($500),
five 1, asownero(thepro
❑ I, as owner the property, or my employees with wags as thele sole
pp/py
POWER DEVICES UR
rs
a • .
SWIMMING POOL ELECTRIC
VALLIi. 11N
oO C:V
,
- OUTLETS-SWITCHFSHXTURFS
NEW RESIDENTIAL ELECTR SQFT.
5TOWFS
TYPECONSIRUCTION
compensation, li Is
workfessio atrudurehrotIntended oroffered for
Business Code: The Contraorimpctofe License Law
sale (Sec. 70Knotapply
TOTAL:
.,
Q'ry, t; ,'' PLUMBING PERMIT FEE
PERMIT ISSUANCE
toanewandf pruperly
wh.d apply town ownerofprough hisonemporimprovesthereoRand
Impmeementsworktintededorough hlsowne. If,h veprovided that such
Improvementsarenot Intended earmfoo torsion.((however, deer ill have
Improvement insoldwithln oneyearo(compldlon,rhe owner-bullderwlll have
til".rden ofpmv)ng that he did not build or improve for purpose of sale.).
Lm
J L as owner of the property, am exclusively ntmenst; with licensed
contractors to construct the project (Sec.7016, Business and Professions Cade:
OCC. GROUP
(,
RFS. UNITS
FLOOD ZONE
APN
The Contractors License law does not apply to an owner of property who
W
builds or Improves thereon, and who mntrads for such pcojeces with
gatpctor(s) Licensed pursuant to the Contodoea License Law.
LII am exempt under Sec. B & P C for this reason
ALTER-DRAIN & VENT -WATER (EA)
BAC]( FLOW PROTECT DEVICE
FEE SUMMARY .
DRAINS. FLOOR, ROOF, AREA, COND.
FIX'NRF_S PER TRAP
SANITARY Y N�
RECEIPT N
Owner Date
WORKMAN COMPENSATION DECLARATION
°( consent to eel(-Inw
C31rm I hereby affithat I have • certlflcercor
SCHOOL TAX Y— N_te
- ,
'3800 aWorkers'CompematioalmuranmoraadifWmpythereof(Sec.
3800, Lab bC C)
p
RECEIPT M
GAS EA.SYSTEM-11NCA OITILETS.
—
PARK FEE Y N
RFGEITM
C.
Com any -
GAS EA. SYSTEM-OVER4(EA)
BUILDING DIVISION FEES
„ �CeNijed copy h herebyumie cityed.
�.elf((led copy h (Red with the city inspection division.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
'(fhbwdion need not be completed If the permit ie(or sane hundred dollars
($1 W)orlessJI certify that In the perfornmence ofthe work forwhich fl4f. Permit 1. Issued,
I shake not employ any person In any manner an as to become abject to the
Worked Compensation Lawn of California. Date
Applica
NOTICE
should ETO esubjsAM:e Warrm'Co this Cationp eis Exemption, you
Code, becomesubjectt°theWorkers' C°mpewtlons orthioruofthe Labor
Code, you inked. with comply with such previsions orthh permit shall be
deemed revoked.
PAID
Date Recei t�
SEWER -SANITARY -STORM EA,20OFT.
WATER HEATER W/VENT/RLEGTR
ENERGYFEE Y N
PAID
Date Recei tit
WATER SYSTEM/TREATING
NEW RESIDENTIAL ELMS._SQFr.
TOT
BUILDING �
-
TOTAL
SEISMIC FEE
ELECTRIC FEE
CONSTRUCTION LENDING AGENCY
lherebyaork that them forwhichthamretmttion lending 0W,Civ.C.) perform
once o(the work for which lhle permit Is issued (Sec, 3097, Civ.C.)
Iendrea N'a've
Lender's Address
IcertifythatITuve readthio.ppHDationaM stateth.Ithe.bovel.f..rt loss
- -
TY.
QMECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
FEES PAID:
iscarrect. I agree to comply with all city and county, ordinances and slate laws
PERMIT ISSUANCE -
relating to building cummuction, and hereby authorize representatives of thio
city to enterupon the abovcmentioned property for inspection purposes.
(We) agree to save, Indemnify an d Loop harmless the City of Cupertino
against liabilities,judgments, mstsand expenses which may in anywayamme
eagainst s���}}}d Citylr cora race g�the granting of this pemnit.
A /F//�� /�
ALTER OR ADD TO MFCH.
-
AIR HANDLING UNIT fro lo,"CFM)
Date R evel Ptil
SUBTOTAL:
AIR ]iANDLINC UNIT tO,DJOCFM)
SITUS TAX
Signature of Appllca /Contractor Date
EXHAUST HOOD (W/OUCH
ONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DI SCLOSURE-
WilltheappHontorfuture building oavpart atom or ha ad le hazardous
material an defined by the Cupertioo Municipal Code, Chapter 9.12 and the
Health anciSafety Cade Sectio. 25532(a)2
❑ Yes No
Date Recei
HEA TING UNIT (TO 100,0D0 BTU) cyY
HEATING UNIT (OVER 100,000 BTU)
TOT
VENTILATIONFAN (SINGLE RESIO)
-
If UL.-
ji
Willserif applicant devices
trrtarmdingoccupant
arxtouor
dbythe Bayussequipment Area
atrrict? arab aa defined by the Ray Arca Air
whicheMa Management
Quality Mawgemrnt DIsMct7
O Illlt�7
BOLER-COMP pHPDA 100,000 BTU)
BORER-COMP(OVPEIW,BBBBTU)
% Ihavemacithshazar�ous nu tedabmquiremenhunder Chapter6.95of
the California Health&Safety Code, Sections 25505,25533 and 25536.1
understand that iflhe building does not currently have a tenant, that it is my
rcapomibillty to roily the occupant ofthe requirements which must be met
—i-0() .)
rr. CJ N
NEW RESIDENTIAL MECH, SQ.Fr
prior to Issuance of a Certificate ofOavpanry.
"
BLDG.i ECTI/aONOcoETTPIIANNR��TM I
F�Mfi
mi
Ownerar auihzed agent Date
-
TOTAL
1SSUEDBY� tiCiY•t;a
OFFICE COPY