23742 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
ng Address°
BuildingProject Identification PERMIT NO.
Buildi2 3 7 4 2
10100 e o a3� `ZD,
ne
one: ALDA I,
t c° \V l�� �'�, lG �.1E.� CITY OF CUPERTIN0.BUILDING DIVISION
11 mracmu.N.me: Lie.No APPLICATION 1 PERMIT
ArchltM/En neerBUILDINGELECTRICAL.PLUMBING.MECHAMCAL CATECCIRY CO
NTre
Llc No:
B
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE �� �/r
LICENSED CONTRACTOR'S DECLARATION
NSA %Fp
Ihth Sb iDA7000atlamg.e 3.d under fth.Supr..b deoff h on Code, mane MI'LIANCESRFSIDENML JOB DFSCRIPDON
Ingres t Section ftme of Division3ofthe Buslnevand Pro(esstonsCade,and my
limnse is In fail force and dfed. PANELS .�.
Lhxm.Clan LIC# t
Date Contractor
ARCHITECTS DECLARATION 1014000 AMPS
q�v Q `
ZO I underetand my plans shag be used as public record.. OVER 10W AMPS SQ.FT.FLOOR}
SPECIAL AREA 5/SQ.FI.
ti Licensed Professional SIGNSELFATRICAL f 1 LlO /it
6 OWNER-BUILDER DECLARATION 1 —� { �TT
toCIRCUIT/MISC I
s-
��/' m am Ihereby affirthat lexempt from the Contractors L
kenm law(orthe 11 1
M: followingresson.(Section 70315,Business and Penfealons Code:Any city or
TEMP.METER OR POLE INST.
� county wM1kb requlresa permit[°rorutruct,aller,lmprove,denaWh,'rrepalr
an yatmmmpdortoits ante,alenmquimatheapplrantforsuchpermitto POWER DEVICES
the a.igned statement that he b licensed pursuant to the provisions of the
3µy Contravenes License Law(Chapter 9(commencing with Section 70M)of Divt- SNRdMING IY)OL ELECTRIC VALUATION
0
F Ift sion3 of the Business.fid Prefessioos Code)orthat he b exempt therefromand.•77 the baa]s for the alleged exemption. Any violation of Section 7031.56y any [mE.IS5N7.ICI-IFSFlXIVRES ��' '. CSrj �^
appBrant for a pealle ed exe prion. Any vioation of natty of not.5 by any
J V !a/
C, °� five hundred dollars($500).
A NEW RESIDENTIAL ELECTRSQ.FT. STORIES TYPECONSIRLICTION
<n ❑1,as owner of the property;or my employee with wages r their sole
t compensation,will dess and Peand the atmaNrehe ren Contender Licerea,d for
Law
5 O sale(Sec 7064 Business and Profealons Cade:The Contranota Llcetue Gw
$$ does not apply to an owner of property who Wilds or improves thereon,and OCC.GROUP RES.UNITS
who doessuch work himselforthrough his own employees,previdedthat such
Improvements arc not intended oroffered forsale.If,however,the building or T6&21
Improvement beold withinoneyearo(c'mpidlogthe°wner-bullderwill have
Irden of proving that he did not Wild or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE
as owner of the property,am exclusively contracting with Iknowd FLOOD TONE APN
me to construct the projeve(5ee 7074,Business and Professions Code: PFRMITLSSUANCE
Contractors License Law don nor apply to an owner of property who ALTERDRAIN&VENT-WATQt(FA)
Wilda or improves thereon, and who contracts for such -
pt'fects with. �'^ FEE SUMMARY
c7gactor(s)IkenxN pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
I_J I am exempt under Sec B &P C for this reawn
DRAINS-FLOOR ROOF,AREA,ODND. SANITARY Y N_
Owner Data
RECEIT N
WOR KMAN COMPENSATION DECLARATION Spi00LTAX Y N.
❑1 hereby affirm that I have a certlflote of consent to self-Insure,m a FIXTURES. �R TRAP �_ RECEIPT#
mAtflateof Workem'Comper donlmumnmoramdif[d cepythereof(Bec.
3800,Lab C.) S GAEA.SYSTEM-I 1NC.40I1TLEI5 PARK FEE Y N
Policy# RECEIPT M
GAS FA.SYSTEM-OVER 4 MA)
ons any BUILDING DIVISION FEES
Certified copy is fit.l.hed.the city REASE/IN Erroll PLANCHECK PGE Mt
❑Certified copy b hereby with the city Inspection division,CERTIFICATE OF EXEMPTION FROM WORKERS• —mmw PAID
COMPENSATION INSURANCE pOp-p Date �1
(Thlssectlon need not beeompleted lithe permit b for ane hundred doHan
m0fi>'r less.) .�lY/V /ELECm ENERGY FEE Y
I cent employ
o anyhe person i c of any m worknner forwhl b cols permit issubjec bevel, _ �O
I shag not employ any person in any stunner m u to become subject to the WA SYSTEM/TREATING PAID f e
Workers'Compe...Hon U..f CaBfomla.Date
O Z ApplicaNOTICE RFSIDF!gi LP B._SQ.Er. Date Recei t#
Z NOTICE TO APPLICAM:$after making this Certificate of Exemption,you
d�ede,Yo come sf.Ah othe comply
such pruatlon provbl°nsoTihej+b�t - A.. TO L:
fA del edrevwet forthwith comply wllM1 each provisbns or th6 pe tsNa3ih� _
UILD
W ] deemed revoked. LL 1 t
CONSTRUCTION
mctionNG AGENCY J SEISMIC 'E
Il Z lherebyafflrmthat mere lsaconstroctlon lendingagenry for the ped�in 1- T ELECTRI
anceof the workfor which this permit is lssued&c.3097,Civ.C.) , J
Q Q Landers Name _ PLUMW19C PEJr
LL h- Lender.Address 3 TY!` —MECHANICAL PERMIT FEE MECH NI L ••E
OW Imdlfythatl have readthLsappBeaOnn and dalelhatthe above information
C Is correct.I agree tocumply with all city and county ordlnanmandstate laws PERMITISSUANCE _- FEE A
Y relating to building construction,and Mmby authorize representatives of this
N city
[— to enter upon the abcwenrentloned property for bupeveion purposes. l ALTERORADDTOMECH. se,Z (We)agree to save,indemnl keep harmine the City of Cupertino ate Receipt#
Q against llablliles,}adgnxmt.,co sande pe nes whkhmaylnanywayacerue AIRHANDLINGUNFICT010,WOCFM) SUBTOTAL:
.go 1)
by Leconseque ofth antingofthlepermit.
S_ AIRHANDUNG UNIT(OVER 10,000CFM) RUC NTAX
SI o Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCT N TAX PAID:
HAZARDOUS MATE IALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT 100,000 BIT!) --^ pate Re i t#
materbl as defined bythe Cu rtino Municipal Code,Chapter 9.11,and the
Health and Safety Cod Sc on 15531(a)7 HEATING UNIT(OVER]0,000 BTU) '1'
❑Yea No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) IS UANCA�T
which emit hazardous�ab'�eow'Tljam+��IIinsMass defined by the Bay Area Air I�YJ
Quality Management rd BOILER-CAMP OHPOR 100,000 BTU)
4 Yn No
have read thehva sus materlaLs requirements under Chapter 8.95 of BOILER-COMP(OVER 100,000BM ( �/� I,aa_
the Callfomla Health&Safety Code,Sections 15505,25533 and 25534. I F G �t JUC9
understand that if the Wildin snotaurcntly have a tenant,that It b my NEW RESIDENTIAL MECH. SQ.FT.
ecspomibiI ty(o nalfytheo pan fthc eecrtrnr 'ntswhkh..tbv met "Il / Vr 1aUr fl II"
priortolsv anmo(a Certlf IQ parry.
Owner' authorized agent Date TO ISSUED BY:
OFFICE COPY