23459 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ect Identification PERMIT NO.
t
'BnBding Address: - • - � . 23459
one. A A
am� �» CITY OF CUPERTINO-BUILDING DIVISION ' , ``1� w 7
Contrader N.me: Lm.No: gpp.LICATION I PERMIT `"� 7•�"t
BUILDINGTLEC7RICALPLUMBING-MECHANICAL CATEGORY CONTROL#
Architect/Engineer. Lic,No:
Qn ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:
❑ ❑ [:1LICENSED CONTRACTOR'S DEC—AAPERMIT ISSUANCE TION
Thereby affirm that l am licensed under prov4slecoof Chapter 9(commen APPLIANCES RESIDENTIAL .JOB DFSC ON
Ing with Section 7000)of Division 3 ofthe Buaineeeand Pecltsslon.Code,and my
lice...Is In fullip me and died. PANELS -
LicenaeClaw L �3� Lie#�5.7 '76—
1 ,
Date V Cantrador6 "t7 �1.--
ARCHITECPSDECLARATION 701-1000 AMPS
q�q�uu
W0z0 I understand my plats shag be used u public record.. OVER 1000 AMP5 SQ.FT.FLOOR AREA $/SQ.FT.
Fa Iy�j Licen.ed Pro(eeelarul SIGNSELECTRICAL
<<'G-fEy'1
OWNER-BUILDER DECLARATION .
ZR l herebyaffimn that I a exempt fromthe Contractor's License Law for the SPECiALCIRCUIT/MISC
0n,.. following reason.(Sect1on 7031.5,Business and Profession.Code:Any city or
" TEMP METER OR POLE INS!.
F tcountywhkh regulresa pemNtt0 construct,alter,Improve,demolish,orespalr
any atrudure prtm t.Ma har..ce,a l.o mqulres the a ppbnnt fm such permit to
file a signed statement that hele Ikenaed pureuaot to the proWlors IX of the 1 DEVICES
w Contractor's License law(Chapter 9(commencing with&dbn 7000)of pivl-
�O sion3ofthe Sus .and Professions Code)orthat he is exempt therefromand SWIMMING POOL ELECTRIC
NesVALUATION
6 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLET&SWITCHR&FIXTURES
applicant fora permit subjects the applicant to a civil penalty olnat mere then
Eve hundred dollars(5 M.
�n �I,
...w r
sowr of the property,or my employee@ with wages a,their sole NEW RESIDENTIAL ELECTR SQDT. STORIES TYPE CONSTRUCTION
compensation,will do the work and thestmdure Isnot intended or offered for
q
.to(Set.7044,Business sad Peofessfus Code:The Cm madors Norm,Law
dues not apply to an owner of property who Wilds or impmves thereon,and OCC.GROUP RFS,UNITS
ho doessuch work himself or through hisown employees,provided that such -
improvements are not intended oTOTAL
wr.flered forsale.If,however,the building or :
improvement Issold within one yearofcomple nts,the owner-builderwill have
t"rden of pmving that he did not build or Improve for purpose of sale.). Qn, PLUMBING PERMIT FEE F[pp ZONNE APN
U L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to corstmet the project(Sec 7014 Business and Professions Code:
The Contractor's License law does net apply to an owner of property who AL7FA-DRAW&VENT-WATFR(EA)
bullda or Improves re
theon,and who centrads for such pip)eM with a
151 dor(s)licensed pumantrothe Contractor's Liceve Law,
am FLOW PROTECT.DEVICE FEE SUMMARY
am exempt under Sec. B&P C for this reason
Owner Data DRAINS FLOOR ROOF,AREA,COND. 'SANITARY Y_ N_
. WOR KMAN COMPENSATION DECLARATION RFCErT#
[:]I hereby effidn that I have a certificate of consent to self-Inure,or a MTURES-PER TRAP SCHOOL TAX Y N
certificate of Workern'Comperwtlon Insurance wacertifkd copythereof(Sec. RECEPT N
3BOM,Lb ) z GAS FA.SYSI'FM-1 WC.4 OUTLETS
Pollcy# Q. q PARK FFF Y N
RECEIn
Com anv shere � GASEA.SYSTFMAVER4(FA) ' BUILDING DIVISION FEES
y��CertiB copy ishere eted. GREASE/INDUFTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy V(fled with the city inspection division.
CERTIFICATE OFEXEMPTION FROM WORKERS' GREASE TRAP SEWER SANRARY PAID
COMPENSATION INSURANCE
(Thlswetion need not be completed lithe permit isforone hundred dollars STORM FA.200FT. Date Recei t#
31 I cortifess.) the -C ENERGY FEE Y N
(certify that lnanypeoron inan ofthe work fc,which this Permit 1. WATER IiFATER W/VENT/EI.ECTR
I ork not employ any person In any manner w as to become subject to the
Worken'Compensatlon Laws of Calaornla.Data WATER SYSTEM/TREATING PAID
O Z Applicant Date Recei t#
'Z O NOTICETOAPPLIGNT:If,aftermaking this Certlfkateef Exemptionyou NEW RESIDENTIAL ELMS, :[1Ff.
sbould become eubjeet to the Workeri Compensation provisions of the shot TOTAL:
Wy Code,you must(orthwilh comply with such provisions otibia permit shell be
> deemed revoked. - BUILDING FEE
a C CONSTRUCTION LENDING AGENCY - SEISMIC FEE
I herebya/flrmthat there Is a mmtrodm
ion leading agency for the perfor -
Z ance ofthe work forwhichthis permit is Issued&c.3097,CIv.C.) TOTAL: Hwy ELECTRIC FEE
(.) 0 Lender'.Name i PLUMBING FEE
U. Lenders Addmss QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W kakifythatlhavereadthisappil.lt nandetatethattheabovelnforma....
G iscorred.I agree to complywlth all cityaad rountyordinancesand state law. PERMITISSUANCR FEES—PAID-
city relatingtobuilding corstrudion,and herebyauthorlae representatives ofthls _
F Z city to enter upon the above-mentioned properly for tospedbn purposes. ALTER OR ADD TO MECH.
— (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
against liabilities,ydgments,cod.and expenses which may In aoywayaccroe AIR HANDLING UNIT(To ron10,000 CFM) SUBTOTAL:
against said City In sryuence of the granting ofthls pem it.
AIR HANDLING UNIT(OVER 10,000 CEM) CONSTRUCTION TAX
re of Applicant/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT CTO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter9.lZ and the Date Recei t#
Health and Safety Code lion 25532(a)7 HEATING UNIT(OVER 100,000 BTM
71Yes TJNo TOTA
Will the applicant of future building occupant use equipment or devices VEMIILATION FAN(SINGLE RESID)
w ISSUANCE DATE
which emit hazardous air contamloanta as defined by the Bay Area Air
. silty Management D7 - ROLLER-COMP OFNOR 1010,D00 BTM
Yes No
ave read thehaza us materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTM the pN
the California Health&Safety Code,Sect lora 25505,25533 and 25534.] P9 Y
understand that if the building does not currently have a tenant,that it Is my NEWRESIDENTIALMECH. SQFT
reapmmlbllIty to rally the occupant of the requbements which must be met ��� ��
rtoisuar6cfa rti8 teof0emparcy.
19C.
net or authorized agent Date
TOTAL: ISSUED13
OFFICE COPY