23398APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Address:Rip, y P~ e1T % C�-r,
PERMIT NO.
23398
corers ansa: one:
(� as?z q 4 k +Q
CITY OF CUPERTINO4BUILDING DIVISION
, APPLICATION I PERMIT
HUMDINGELECTMCALPLUMBING-M liANICAL
p
tracoul. a Lie. No:
^� , d
rchltect/Engineer. Lk. No:
CATEGORY
CONTROL#
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:
PERMITISSUANCE
Imo, ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under previsions of Chapter 9(commenc
with Section 7000) of Dlvisien3 ofthe Busloses and PrelessimeCode, and my
license is In full force qjBI effect
LlcenseC se LIeX
Dale Contractor-L!-..At�,NN
CHITEGT E LA AT
APPLIANCES -RESIDENTIAL
PANELS
UP TO 200 AbMS
JOB DESCRIPTION
.i4, pI
C Iii/.Y
i� C•�
pl-1 WOAMl'S
OVER 1000 AMPS -
SQ. Fr. FLOOR AREA
$/SQ. FT.
I understand my plans shag W used as public records.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt fmmthe Contractors License Law fm the
following reason. (Section 7071.5, Business and Professions Code: Any city or
cmntywhich requires a permit tocorstmd, alter, Improve, demolt.h,ormpalr
anystmcture priorto its issuance,at.orequlrestheappliant for such permit to
file a signed statement that he Is licensed pursuant to the provisions of the
Contractor'sLicense Law (Chapter 9(commencing with Section 7000) of Divi-
ivi-
sion
sion3 ofthe Business and Professions Code) orthat he is exempt therefremand
the beat. for the alleged exemption. Any violation of Section 7031.5 by any
applicant for a permit subjectsthe applicant to a civil penalty of not nnrethan
five hundred delta. ($500).
I, a owner .(the property, or my employees with wages as their sok
SPECIAL CIItCU[T/MIST
.(Ery{# METER OR POLE INST.
POWER DEVICES
gWQdMgNG POOL ELECTRIC
VALUA7I
C
I✓
OUTLETS-SWITCHESHXT[JRES
NEW RESIDENTIAL ELECTA FT.
Q
STORIPsS
TYPE CONSTRUCTION
compensation, wllldo Ne work andthe structure h not intended or offered for
sale (Sec. 7044, Business and Professions Code: The Contractors License Law
does not apply to an owner of property who Wilds or improves thereon, and
who doessuch work himself or through hisown employees, provided that such
OCC.CROUP
RES. UNITS
improvements are not Intended reoffered forsak. If, however, the W ilding or
improvement ksold within.neyearo(completloo,the owner-bullderwlll have
t"rden of proving that he did not build or Improve fee purpose of sale.).
u L as owner of the property, am exclusively contracting with licensed
contractors to construct the preject (Sec. 7054, Business and Prolesskrs Code:
The Contractor's License Law does not apply to an owner of property who
Wilds or improves thereon, and who contracts (or such pwiecta with a
cm
cgp[fa(s) Banned pursuant to the Contractor's License Law.
1 am exempt under Sec. B & P C for this reason
TOTAL:
QTy. PLUMBING PERMIT FEE
PERMIT ISSUANCE
--
ALTER -DRAIN &VENTWATER ears)
FLOOD ZONE
APN
gpQg FLOW PROTECT. DEVICE
FEE SUMMARY
OUTSIDE F1zFq
DRAINS 700a
FD(T(RiES PFR .p
SANITARY Y_ N_
RECEIPT If
Owner Date
WORKMAN COMPENSATION DECLARATION
01 hereby affirm that I have a certificate of consent to self -insure,
SCHOOL TAX Y N
ora
certifimteof Workers'CompomaHontmuranaoraudifk mpythemof(Sec.
3000. Lab C.) 999Y
Poll p r
RECEIPT p
GAS PA. SYSTEM -1 ING40UTLETS
PARK FEE Y N
D
Coma Y
Gem a cop t. ercby umb ed.
rtl(ied copy t. filed with the dty Inspection division.
GAS EA. SYSTEM-OVER4(EA)
BUILDINGDING DIVISION FEES
GREASE/INDUSTRL WASTE INTERC
51L'�
PLANCHECK FEE
GREASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
TThlssection need not be completed lithe permit Is for one hundred dollars
($tI rrless.)
so as to bcomethis emnitt. issued,
Icemfy thatoy In anyhe Pence,
I shall not employ any pereon f any manner n as to become subject to the
any
Cempewdon Laws ofCaltfomta. Date
W Applicant
Applicant
after makingthisCertnlPre of Exemption, you
Nould how subject to
should become subject to the Workers' such Prsatlon pmvhimu of the Labor
CodGYou
revolo forthwith comply with such provhlrns or this permit shall be
deemed revoketl.
PAID
Date Recei t#
SEWER -SANITARY -STORM EA 200PT
WATER HEATER W/VFNT/ELECTR
ENERGY FEE Y N
PAID
Dare Remi t#
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB.SQ.FT.
TOTAL:
BUILDING
.-r
TOTAL:
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby afBrmthat there is a construction lending agency for the perform
ante ofthe work for which this permit t. Lowed (See. 3097, Cie. C.)
ELECTRIC FEE
Under'. Name
Lender's Address
I cemfythatl have macithisappliatlonand statethattheabove information
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
FEES PAID:
t.cornect. I agreeto comply with all city and county ordinances and state laws
PERMIT ISSUANCE
relating to building construction, and hereby authorial representatives of this
city to enter upon the above-mentioned property for inspection purposes.
(We) agree to ave, IndemNfy an�keph the City of Cupertino
srsan may In any wayaccrue
ags permit.
d
Date Recei t#
Pag=WmofA/C.ftF.?r.r1
ALTERORADDTOMECH.
AIR HANDLING UNIT( To la," CFM)SUBTOTAL:
AIRHANDLING UNIT (OVER 10,000CFM)
CONSTRUCTION TAX
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
—Jzz to
HAZARDOUS ATERIALS DISCLOSURE
HEATINGUNIT(TO 100,000BIIn
Will the applicants future building occvp..t,t...rh.cdle hazardous.
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Ilealth and Safety Cod a�+.�Section 25532(a)7
ED Yes u No
Date Recei t#
HEATING UNIT(OVER 100," BTU)
TOTAL' a
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
®® pp 1
P M 7
1111AD 1 O ��
MAR AR s99
Will the applicant orfuturc building occupant use equipment or devices
which clout haramous air contarouseaaa defined by the Bay Area At,
Quality Management DisMct7
Yea❑❑ No
I have read the bazardrus materials mqulrements under Chapter 6.95 of
the California Health & Safety Code, Sodium, 25505, 25533 and 25534. 1
understand that If the building does not currently have a tenant, that it hmy
responsibility, to redly the ..part of the requirements which at be erre
BOILER-COMP(3HP OR 100,0(0 BTU)
BOILER -COMP (OVER TOO,000 BTU)
-
NEW RESIDENTIAL MECH.
prior to unarm of a Certificate of Occupancy.
��-.���u�
CIV x Of\ULpa ICir Erwa'
ISSUED BY �«f
d
Owner or aulherlaed agent Data
TOTAL:
OFFICE COPY