23194 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification ' '" - -sPERMIT NO.
Building Address: 23194
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wnercarse:
SUSG n ✓ err ^ems//C CITY OF CUPERTINO-BUILDING DIVISION
C,no-a , .Name: 7 Lic.No, • APPLICATION I PERMIT
e✓ - BUILDINGELECTRICA1,PLUMBING-MECHANICAL` CATEGORY CONTROL M
Architect/Engineer, - Lk.No -
. ( .t .. tt y�. it')ia?BUII,DING`PERMIT,INFOt
EL$CTRIc PER1l4IT • 5 F r E,
Address .. _ PERMITISSUANCE .. �.
LICENSED CONTRACTOR'S DECLARATION - -
Ihereby affirmthatlamlleemedunder provisions ofChapter9(commenc- APPLIANCESRESIDENTIAL JOB OESCRR'TION
ingwlth5ect1on7000)of DlWsion3o(ihe8ustneseand Professtons Code,end my - I" I..L�J
license lain fullfq¢e,lgd erreR. 3 PANELS V7, r` �l
Lkense Clam Llc p /� -/cE n
Datta /i://,moi Contractor -
/]/V�'F- ARCHITECTS CLARATION -
201-1000 AMPS
reO ZpO [understand my plan co
slvll be used as public records. OVER VER1t(p0 AMPS SQ.FC.FLOOR AREA g/SQ.Ff.
R�t, Licensed Professional SIGNS ELECTRICAL
e' 6WBER-BU1LDER DECLARXEION SPECIAL CfiIRCUIT/MLSC — -� „ ^
IJ A V
1.., I hereby affirm that am exempt from the Contractor's License law for the
0 oo following reason.(Section 70113,Business and Professions Code:Any city or F' f - ER
KZ1"' muntywhich requires a permit tomnstruct,alter,improve,demolhh,orrepair TEMP. INST. 1 j- ��=
`a anystructure prior[,its isavance,aborequirarthe applirantfor such permito POWER DEVICES
file a signed statement that he is licensed pursuant to the provistom,,f the Z
Contractor's License Law(Chapter 9(commencin with Section 7000)of Divi-
{{{...30�^ sion3oflheeusiness and Pm(emiom Code)orthagheis exempttherefromand SWIMMING POOL ELECTRIC DALE - VALUA0=s '
O the basis for the alleged exemption. Any violation or Section 70)1.5 by any OU7IETSSWITCHFSFIXTUR L/ /I
applicant for a permit subjects the applicant to a civil penalty of not more than
rive hundred dollars($500). NEW RESIDENTIAL ELECTRSQ.FT. STORIES TYPE CONSTRUCTION
I,as owner,of the property,or my employees with wages as their sole
compensation,will do the work,and the structure is not intended or offered for
O sale(Sec.7114,Bosoms and Pmfesdons Code:The Contractors Licetue Law
S$ does not apply to an owner of property who builds or Improves thereon,and OCG GROUP RES UNITS
EE who doessuchworkhimselforthemigh hisownemployees,provided that such
improvtrot.tsarenotinlendedororferedforsale.lf,howevegthebuildingor TOTAL:
improvement le soldwithinoneyearofcompletion,the owner-builderwill have
t elan of proving that he did em build or improve for purpose mania.).
Qjy.'�, ` _ELUMBING�PERMIT ticFEE`•+° FTADDTDNE APN
L
L act owner of the properly,am exclusively contracting with Ikeneed PERMIT ISSUANCE'
contractors to construct the project(Sec.7044,Business and Professions Code: '
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN,&VENT-WATER(EA)
build.or Improves thereon, and who contracts for such piptecta with e'
co,,66t{{actor(s)licensed purmante,the Contractor's License Law. - t ,.
L)I am exempt under Sec B&P C 4,r this reason BACK FLOW PROTECT.DEVICE SUM�'IARY
DRAINS FLOOR ROOF,AREA.COND. SANITARY Y_ N_
Owner Date RECEIPT p
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N
hereby affirm that I have a certificate of consent to self-mane,or a RECER'T#
reAlficate.fWraloos'Compn .it.Iromme.or a certified copy thereof(Sec.
3800,Lab C.) GAS EA.SYSTEM-1 ING40[TILET5 PARK FEE' Y N
_
I'0licy# GAS EA.SYSTEM-OVER 6(EA) RECEITT#
Com anv /j2PY/dG2/! eft} BUILDING DIVISION FEES
erti0e copylsherebymmle'ned. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
E]Certified copy le filed with the city impection divielon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP • PAID
COMPENSATION INSURANCE SEWER-SANjTARY-STORM EA.WIFE. Date ReCe1 t#
(Thlssection need not be completed tithe permit b forone hundred dollars
($100)or less.) 11
WATER HEATER W/VENT/ELFCTR ENERGYFFE Y_ N_
I certlty,that in the performance of the work for which this permit I.taking, ,
I shall not employ any person In any manner so as to become erb)ect to the „ _
Workem'Compeneatlon LaLamo(CalifomW ATERfa.Date SYSTEM/TREATING PAID
O'Z Applicant - NEW RESIDENTIAL PLMB: SQFC. - Date Remi t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation profislom of the Labor . TOTAL:
Code,you mart forthwith comply with such provide.oTthis permit shall be BU
W'> deemed revoked. _
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a G I hereby arfirmthat there Is a construction lending agency for the perform - ELECTRIC FEE
Z anceortheworkforwhichthl.permitLl.sued(Sec.W97,Clv.C.I TOTAL
fJ O Lender.Name t ,t . PLUMBING FEE
U. H Lenders Address - QTY: ;?-, MirC7-IANICA4'FLRMIT.I,' .:,FEE:`
O W Icomifythatl havereadthi.applicationand statethatlheabove Information "1� MECHANICAL-FEE
4 is correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE ' FEES PAID:
} W relating tobullding corstruction,and hereby authorize representatives ofthls
cityto enteru on the above-mentioned ro for inspection u sere. ALTER OR ADD TO MECH.
Z (We)agree m save,Indemnify an d keep harmless the ity of Cupertino - Date Receipt#
V 'against llabieties,)udgmenh,roars and expenses which may In any way accrue AIR HANDLING UNITED 10,000 CFM) - SUBTOTAL'
against said City in con.erf ce, the granting of this permit. -
Gx(// '7/ AIR HANDLING UNIT 10,OW CFM) CONSTRUCTION TAX
CONSTRUCTION TAX PAID:
Signature of Applicant/ ontraemr Data EXHAUSTHOOD(W/DUCT) .
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or hand le hazardous HEATING UNIT(TO 100,000 BTU) Date Reeel t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER100,o00 BTU) _ TOTAL:
Ve. �]No I .
Will the applicant or future building occupant use equlpment or devices VENTILATION FAN(SINGLE RESID) ISSUAN
which emit hazardous air contaminants as derined by the Bay Area Air r P'� -
.lityManagementDistrict? - BOILER-COMP PHP OR 10gIXB BTU)
� Ye. u, A 1619
have read the Gaza ou.materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) Al
the Celifornla Health&SafetyCode,Sections 25505;25533 and 25534. I 1, s�.#yIs}1saaaa��//�/a)
understand that notifybuilding does
cupam oft a currently haves which]that it Lamy NEW RESIDFNI7AL MECH. SQ.FT. V�
prior to
responsibility ofaCtheocteof iupamrqulrementa which most 6e met
prior to Issuance ofa Certificate o(Qivpancy.,
Owner or authorized agent - Data ISSUr,D BY.,-!
TOTAL:
OFFICE COPY