23716 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project IdentificationPERMHNO.
Building Adr1�ry66 ��� � �� r - 2371 6
s G one: A
CITY OP CUPERTINO-BUILDING DIVISION �.... �,
Contra ora Name: Lie.No: APPLICATION I PERMIT
BUILDING-ELECTRICALPLUMBINGMECFIANICAL CATEGORY CONTROL N
Amidtact/Engineer. Lk.No:
/� QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address J✓! PERMITISSUANCE jje� ❑ ❑ F-1LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that am licensed under provisions of Chapter 9(commene- APPLIANCESRESIDENTIAL JOB DESCRBsI]ON
ingwith Sectio,7000)of Division 3 ofthe Budi caressed ProfeaslonsCode,and my 5D�;Z
time.Is in full form and effect. PANELS
Ltmnse Class//A Lk.N
Date Contractor
UPTO 200 AMPS
CHITECI'S DECLARATION OVEROOAMI'S
pQ+0OZ0 Iundenland my plan he II be used as public records OVER 1000 AMPS SQ.FT.FLOOR AREA 8/SQ.FI'.
E u Licensed Professional SIGNSELECTRICAL P h rN q ® �n\�
6 OWNER-BUILDER DECLARATION SPFCIALCB4CUIT/MISC u ° t+
Iherebyafflmn that am exempt fmm the Contractors Limns Law for the w
o followleg rea.oe.(Section 70315,Budeess sed Pmfevlona Code:An city Or n iryl
O z�:. Y ty TEMP.METER OR POLE INSET. I �. uFR
—
K� co untywhmpeorlmap ancomvtmel,alter, apiluntfr.uchper tlr
�e any atructure priertolbhat he Balcansed restheatateepru isionsof t e pp4ypl(DEVIC�S
w�� file a atgned gatemen[that he ls Bcenead pursuant to the provblov of the DATE
Ou, Contmchu,License Law(Chapter 9(commendng with Bodies 7000)of Divi-Sti VALUATE
OS don3 ofthe Bunienn and Penfenlov Ceds)orthzt he b exempt therefromand SWIMMING POOL ELECTRIC
�.' the bash for the alleged exemption. Any violation of Sadtbn 70)15 by any
<
applicant fare permit subjects the applicant to a civil penalty of not more than OUMEISSWITCHESFIXIURES
Ove hundredsowner of
NEW RESIDENTIAL ELECTR SQ.Fr. STORIES TYPECONSTRUCTION
❑I,as owner It 1M1e a worlty,or my employees with wages as there sok
t 7 a mmpnneation,wBldolhNworkofessi enC d.: ls ot Intended or L�an 1.for
$ ❑ dile(Bee.7004,to an ow and f property
rops ty Code:TM1e or impemra theme Law
pj $ doe notapply fork Kiser offprough hiswho
nemorimproovided eoRand that such OCC.GROUP RES UNITS
0.0.
who does
ments am not
maelf or dedoraugh hleowne.If,howeer,thedildingr,
improvementsarcnot Intended orrofc tomos.ILh ew blhebulldingve
improvementlswldwithlnovyearofcompletloRtheowner-bu0derw8l have '
ft.burdan of proving that he did nm build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
u L as owner of the property,am exclusively contracting with licensed PERMITISSUANCE
contradicts,to conalruct the project(Sec.7044,Business ami Professions Code:
The Comments Limns law don not apply to an owner&property who ALTER-DRAIN&VENT-WATER IFA)
Wilds or Improve thereon, and who contncta for such pkojecb with a FEE SUMMARY
cgp((actorW Boenxd pursuant to the Contractors License Law, BACK FLOW PROTECT.DEVICE
LI f am exempt under Sec. B&P C for this reason
Owner Data DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
RECOFT N
WORKMAN COMPENSATION DECLARATION FLY.NRFS PER TRAP SCHOOL TAX Y_ N
❑1 hereby affirm that I have a certlOcate of consent to salf-imm�,m a R_ NN
certificate a(Worken'Compensatlon Imemece oracertifled ropytherecf(Sac.
3800,Lab C.) GAS F.A.SYSTEM-1 INCA OUTLETS PARK FGE Y N
]bury,M RECEIPTN
CGAS EA.SYSTEM-OVER 4(RA) BUILDING DIV
ISION FE[mCetified S
copy ls hercbyththe GREASEANDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
❑Certified copy I.filed with thecicity ty Inspection dlvtion.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY.SMRM EA 700F1' Date Recei Ip
(ThisaeRlan need nn be<ompicted B the permit ls forov hundred dollen
(f100)or lese3 WATER HEATER W/VEM/ELECTR ENERGY FEE Y N
I certlfythat In the performance ofthe work forwhlch this permit Is batted, —
I shall not employ any person In any manner eo n to become witted to the WATl72 SYS[FM/TREA7IN'C
Workers Compensation Lawaof CaBfnmla.Date PAID
Z ZNO7licant
7CETO APPLICANT:If after nuking this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.Ff. Date Recei tit
F2 should become subject to the WOrken'Compensation provisions of the Labor TOTAL:
N Coca,you at forthwith comply with such provisions or this permit shall be B N 'E
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
M lherebyafflrmthat then lsamvtruRlon lendlegagency forthe perform, ELECTRIC FEE /—
DZ ante of the work for which this permit is Issued(Sec.3097,Civ.C.) TOTAL:
U O Landes Name PLUMBING FEE
LLF Lenders Addmu QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I certify that L have read this applicad....d gate that theabove information
a Isco7.I agree to comply with all city and county ordinances and gate laws PERMIT ISSUANCE FEES PAID:
W triatl ng to bulldleg mvtructlon,and hereby auNomaa representative.ofthis
F V) city to enter upon the above,menBovd property for impettlon Purpose. JALTERORADDTOMECH.
(We)agree m save,Indemnify an d keep hormion the City of Cupertino Date RCCeI t#
V agalnatllab011kro,jadgment,oostand expenm which may In anyyrw�+a)y////casae AIR HANDLING UNIT DO I%M CFM) SUBTOTAL'
agalnat vid Cl In mea once of the agiingofthb�erm LC..(L, R HANDLING UNIT(OVER 10,0D0CFM) CONSTRUCTION TAX
reof Ap dant/Conte r Calls EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfulum building occupant store or handle hazardous HEATING UNIT DO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the Date Recei t#
f Ieaith and Safety Code SectEA
ion 75533(a)7 HEATING UNIT(OVER 100,(00 BTU) TOTA
RYea No
illthe applicant or Nrebuildinif occupant ueeequlpment ordevicea VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminant.as defined by the Bay Area Airp
ality Management District? BOILER-COMP DEEP OR l00,0ID BTU) P ,4 9
Yes n❑No �/
have read the havrdous materials requirement under Chapter6.95 of BOILER-COMP(OVER 100,000 BTU) - �JpAI 21
the Celifomla Health&Saaty Code,Sections 755()5,75533 and 75534. 1 I 1992
understand that lflhe building does not correctly have a tenant,that It is my NEWRMDENTIALMECH. SQ.FT.
responsibility to notify the occupant of the requirement'which .at be restlo
Cl I Y Uf
prior to issuanof a Certificate of Oceps nry. eC,UIY / Lissuance,Owner or authorized agent - Date ISSUED BY: �^ '1�
TOTAL:
OFFICE COPY