23062 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Addresr. 23062
wnsra a . Irome:
CITY OF CUPERTINO-BUILDING DIVISION '
contrsnor'. came: Ida. m APPLICATION /PERMIT
a
; - — UILDINGMMnUCAIMUM lNGM HAMCAL CATEGORY CONTROL N
ec, neer. Lic.No;
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMIT ISSUANCE W any I K
LICENSED CONTRt under provisions
L,} �/�
I hereby ion7OOhafDiviglam m3ofthe uMne Woneo(Csions ode,m enc ANCFSRESTDENML �• sr�JOBLI S R11MON
Ingwesin fon to=and effect,
(rheBuaneuand PrvfesalasCode,and my - `9
licences le In full(ora and c.0 PANELS
Lkxnm Clan LIc.N
Comeact r
ARCHITECTS DECLARATION Mi-l"AMPS
re0 20 I understand my plans shall be used as public records. OVER 1000 AMPS SQ,FT,FLOOR AREA S/ .FT
QE Licensed Professional SIGNSELFGTRICAL N A LED t
<6LA° OWNEReBUILDER DECLARATION IAL CIRCUIT/M19C p M P U T R
7r IherebyaffirmtOWarn NER-HOLDER the Contractor's License law to the
oo (o0owing reason.($eLTlna 7015,Business and ProlenWns Code:Mynty or
I-' county which requlnsa permktororatruct,alter,bnpmve,demolbh,orrepair TEMP'MEITRORPOLEINS ��„
anyatmdure prior toits Issuance,also requires the eppeant for permit to .�.
Ella a signed statement that he Is licensed pursuant to the provisions of the ]OWER DEVICES
O w Contranor's License Law(Chapter 9(commencing with Section 7000)of Divi-
�OS s1on3of the Business and Professio.Code)orthat he la exempt therefromand SWIMMING POOL ELECTRIC VALUATION
Iao
2 ' COO.a
< appliantfor a permit subjects theapplicant to a civil penalty a not more than UTLESSW7TCHFSFIXTURE5
he basis for the alleged exemption. Any violation of Section 7015 by any `Q
0 five hundred dollars($500),
'9..' I,as owner of the property, NEW RESIDENTIAL ELECTR SQFr. SIORIFS TYPECONSTRUCTION
�n ❑ p perry,or my employes with wage as their sole
compensation, endthestrodure V nm Intended or o(femd for
O
.1.IS.70th,Business and Professions Code:The Contracioes License Law
$ don not apply to an owner of property who Wilds or Improve,thereon,and OCC.CROIIP RES.UNITS
who does such work himself athrough his own employee,provided that such'
Improverrentsare not Intended oroffered for sale.I(however,thebuildingor TO
Improvementia oldwithinoneyearofcmnpl&Wmtheowner-builderwBlhave
OHLItrden of peeving that he did not build or Improve for purpose ofins.). PLUMBING PERMIT FEE FhOO ZONNE APN
LJ L as owner of the property,am exclusively contracting with llmnsed PERMITISSUANCE
contractors to ronstmct 90,the project(See 70Business and Professions Code: Ty. -- .
The Contractor's License law does not apply to an owner m property who ALTER-DRAIN&VENT-WATER(EM
Wilds or Improves thereon,and who contracts for such ixp"with a FEE SUMMARY
cgB((ct
aons)Ilansed purmentrothe Contractori Limme Law, BACK FLOW PROTECT.DEVICE
l_l I am exempt under Sec B&P C for this mason
•
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N Owner Date RECEIPTN
WORKMAN COMPENSATION DECLARATION FIXTURE&PER TRAP SCHOOL TAX Y N
❑I hereby affirm that I have•artiftate of consent to•elf-Insure,ora �'� �®H,N
malfluteofWorken'Comper flon Wumnaoraartlfiedmpythennf(Sec.
380,1ab CJ GAS EX.SYSTEM-11NC.90UPA
TLEIS RK FEE Y N'
Policy N RECEIPT N
Coacq= y GAS EA.SYSIT2d-OVER9(EA) BUILDING DIVISION FEES
I ICytiOed copy is herebyth the cid. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
i ied copy b Bled with the ay W pectlon division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
ee
COMPENSATION INSURANCE y.EWER SANITARY STORM EA 200T Date Recel tq
(fhlssectlon nd ns.becomplcted tribe permit V fororte hundred dollen
(El0)"Ifyth WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Illnot thatInthe Person
uInannce tmannerhe work so a to which
eesmitbhated, —
I shall not employ any Penson In any manner m u to become abject to the WATER SYS EM/TREATING
Workcrs'Compenutbn Lowe o(Gllfomla.Date - PAID
O Z Applicant
Z O NOTICE TO APPLICANT;If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQFr. Date Recel tN
Hshould become subject to the WorkerCompensation provisions of the Labor - TOTAL:
W Cade,you most(on hwith comply with such provlaons or this permit shall be
deemed revoked. •E
W 5 CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Z IherebyefOrm that there Is a construction lendingagency forthe performTee ELECTRICFEE
arm of the work forwhlch this permit la Issued eSec.3oC1V.C.)
U O Lender's Name PLUMBING FEE
LL F Leod.e.Addreu QTY. MECHANICAL PER IT FEE MECHANICAL FEE
O W Icedlfythatl have readthtsapp0atbnand astethatheaboveln(armaHon ��
1 Iscorren.l agreeto comply withal city and county ordinances and stalelaws PF2(MIT ISSUANCE FEES PAID:
W relating tobullding construction,and hereby authorize,representatives ofthh
Z city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADDTO MECH. Date Recei [q
(We)agree to save,indemnify an d keep harmless the City of Cupertino
against llabWOes,judgments,costsand expenses which may lnenywayaccrus AIR HANDLING UNIT(TO 10,ODO CFM) SUBTOTAL:
against said City In arm f the granting of this permit. '
AIR HANDLING UNIT(OVER 1 DODOCF'M) CONSTRUCTION TAX
Sig atom of Applicant/C actor to EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA2AR MOUS MATERIALS DISCLOSURE
Will the applicant orfuNm buildingoavpant store or handle hazardous HEATING UNIT CFO 10,00 BTU) Date Recei tp
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(a)2 HEATING UNIT(OVER 10,00 BTU TOT
ElYes No
AA
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contsmirunts as defined by the Bay Area Air
Quality Management Dismiss? BOILER-COMP OHP OR 10,000 BTU)
[?YeeNo
have read the],vQ uematerlals requirements under Chapter 6.95 of BOILER-COMP(OVER 10,00 BTU) A a
tha Callfomla Health&SafetyCode,Sections 25505,25573 and 25539.I NW
understand that lfthe building does not currently have atenangthat it ismy NEW RESIDENTIAL MECH. SQ.Fr.
responsibility to notify the occupant of the requirements which must bemee ®E^
prior to issuance of a Certificate ofOccupency. �9
Owner or authodzad agent Date ISSUED BY: - f
TOT ..
OFFICE COPY