23458 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification. - PERMIT NO.
Build ing Address:
23458
wneraName: - one;
Lnuts L CITY OF CUPERTINO-BUILDING DIVISION -
cpy °N°^a' e.NN. APPLICATION 1 PERMIT
OROJ BUILDINC-ELECTRICAL PLUMBINGMF LAICAL CATFfAR CONTROL p
Architect/Engineer: - - Lk.Nee
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address; PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under pervislonsol Chapter9(commenc- APPLIANCES-RESIDENTIAL JOB DESCR11x770N
ingwllhSeelon7000)of Dlvision3ofthe BusinessandpmfessimsCode,and my
BE
le In fR11 f rce d effect. PANELS O
LlrensnCa�]e{i�"'�.Lk.p v
Dale (e^9"L Contractor YIL(0UP TO 200 AMPS
ARCHITECPS DECLARATION 201-1000 AMPS
IQ+�90 Zp Iundersand my plans shall be used as public records. OVER100o AMPS SQ.FT.FLOOR AREA $/SQ.FT.
E z(/ Licensed Professional SIGNS ELECTRICAL' p
.4 OWNER-BUILDER DECLARATION LS:
/„_ ® „'
X1. 44. Iho.byafOrmthat lamexempt(.the Contractor's License law forth¢ ! V
po following reason.(Section 7031.5,Business and Professions Code:Any city or
OZF-µ9which 'IEMP.MEITR OR POLE]NST.
KSI countycture requires a Permit tocovtmuires thead,alter, provgdemsuch,ermitto 1 11I
any structure prior mitsthatIssuance,lalso
censed pursuant
to the fee proof Dna of permit to ppWpR DEVICES
K�� file a signed statement that he V licensed pursuant to the proNaions of the '
3 re Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWMM(NG POOL ELECTRICVALUA N
sion3ofthe Bodnessasd Professions Code)orthathelsemmpttherefmmand DA
the basis for the alleged exemption. Any violation of Section 70115 by any .J
OUTLETS
applicantm
(era permit subjects applicant to penalty o(not room than SWITCHES-FIXTURES bOo
O five hundred della.($.500). /
'�..' NEW RESIDENTIAL ELECTR S
❑I,as owner of the property,or my employees with wage°as their sole QFI. STORIES TYPE CONSTRUCTION
z compensation,willduthe work and thestructure b not Intended or offered for
D sale(Sec.7094,Business and Profs edom Code:The Contractor's License Law
$ does not apply to ae owner of property who builds or Improves thereon,and OCC.GROUP RES.UNITS
who done such work Mmreiforthrough his own employees,provided that such
Improvements are not Intended or offered for sale.If,however,the building orTOTAL: -
improvement issold witlem one yearofcompletim,the owner-builderwiR have
thellunder,of proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FfAOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE Is+)t
contractors to construct the project(Sec.70K Business and Professions Code: f UV
The Contractors License Law does not apply to an..or of property who ALTER-DRAIN&VFM-WATER(EA)
builds or Improves thereon,and who contracts for such ptojects with a
conactor(s)licensed pursuant to the Common i;License Law. FEE SUMMARY
Ll I am exempt under See B k P C for this reason BACKFLOW PROTECT.DEVICE
Owner pm DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y— N—
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOL TAX' Y N
RECEIPT N
ereby affirm that I have a certificate of concent sure,ora BBC=N
certlI ofWorkeri Compensation lruu.nce ora certi(kd copythpythereo((Bre. CAS EA.SYSTEM-1 INCAOUILETS PARK FEE Y N
Policy
Cd �1Q n '
Polley tl l or-/ �JO'_7RECEIPT«
Com
any GAS EA.SYSTEM-OVER4(FA) BUILDING DIVISION FEES
[gCect1 d copy la herebyCREASHANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
rtifled copy b flied withth the the city
Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARYMRM EA HgFf Date Recei tN
(This section coed not be completed](the permit V(Drone hundred della.
($100)car less3 WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
[artily that lo employ
an Person in an tre ode an as t b Nle permit I.subjec Vto nd,the I
I shall not employ any person In any manner m ss to become subject to the WATER SYSEEM/TREATING
Wwkeri ComnH
penon Lowe of California.Date PAID
0 Z Applicant Date Recei tp -
Z'O NOTICE TO APPLICANT.If,after making l his Certificate of Exemption,You NEW RESIDENTIAL PLMB. SQ.FC.
I" should become subbot to the Workers'Compensation provisions ofthe Labor TOTAL;
N Code,you must forthwith=reply with such provisions orthls permit shall be -
W 9 deterred revoked. BUILDING E
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL z I hereby affirm that there b a construction lendlegagenry,for the perforrry ELECTRIC FEE
Z onceoftheworkforwhichthispermitisIssued(&c.3097,Civ.C.) TOTAL: t50
02 Lander'.Name PLUMBING FEE a Ij
LL F Under's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW 1certify that l have read this application and statethat theaboveinformation
S ismrrcct.I agree to complywlth all city and county ordinances and gate laws PERMITIS5UANCE FEES PAID:
>_ N relating to building mrotructlon,and hereby authorlae representatives of this
Z city to enter upon the above-mentioned property for inspection purposes, ALTERORADDTOMECH. Date ReCei tM
— (We)agree to save,indemnify an d krep harmless the City of Cupertino P
agalrar liabilities,judgments,costsand ex ewhichmayinanyvv amus AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL:
agai Ci In conseq 0; t t ¢permit. _
5 AIRHANDLINGUNIT(OVER10,o00CFM) CONSTRUCTION TAX
Sigw rcof Appllant/ le EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
IIA DOU MATERIALS DISCLOSURE
Will the appR"s future building accvpant store or handle hazardous ]{EATING UNIT(10 100,000 BTU) Date ReCei 1N
material as defined by the Cupertino Municipal Code,Chapter 9.1Z and the
Health and Safety Code Section 25537(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
Yes No -
Will
the applkanter ture building ecapam..equipment or devices VFNTILAUON PAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contamimnts as defined by the Bay Area Air P
ality Marugement DlsMci7 BOILER-COMP pIff'DR 100,000 BTU) p
Yea n❑No a'Y
shave read thehazardwa materia(,requ lrerrents under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health&Safety Code,Sections 25505,25533 and 25539.I �q p
undersand lhatit the building does not currently have a ten ant,that it is my NEW RESIDENTIAL MECH. SQ.FT. d las,9z �\
responsibility to notify the occupant of the requirements which mat be met aJ (Uf�alC~iJJ
prior to issuance of a Certificate of Occupancy. err G,
j:::j
Owner or authorized agent - Date ISSUED BY:
TOTAL:
OFFICE COPY