23594 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
NuildInR Project Identification PF1"TNO.
Building Address; 23594
no i l Bicbb
1A"i TAN (2eK.l > 752--I13 3 CITY OF CUPERTINO-BUILDING DIVISION
CadagLN.: �k. �--7 - APPLICATION / PERMIT
_ BUILDING-1].ECTRICALI'LIIMBINGMECHAMCAL CATEGORY CONTROLS
ArcItect/Engineer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrcsa PERMITISSUANCE 1:1 1:1 1:1LICENSED CONTRACTOR'S DECLARATION
I hereby afflumi that ivisim3ofthe urp salonsar ChionsCo e,and APPLIANCES-RESIDENTIAL JOB DFSCRB'TTON
I corse l SecHon7000)at d effem3ofthe ButlaesandlsrofnsdonsCode,and m
Ilcenx l.In(uB f area effect. r• PANELS /� ���A• �
Date Lk.M_�
Date- Contractor -/s1.i-��
ARCXITE ECL^$ TU /Ram
701-1000 AMPS
re 2 I understand my plans sha0 W used u public rcc cods ` � OVER IOW AMPS f/SQ.FL.
E R
O(/ Licensed Professional SIGNSELECTRICAL ``,. p g -
< OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC U /(IT/A
IMre affirm that l am exemptfromthe Contractor's License Law forthe •y' 4/f�Z
02�@p foow greason.(Scellon7031.5, usiness.edProfession.Code:Mycityor TEMP.MEDRORPOLEINST. /
�'W countywhich requinesa permit tomnatrun,alter,Improve,demolish,orrepairnA
F� anystmu mpriortoitebwame,aborequlnatheappllantfw=chpermitlo
ESI Bk a signed statement that he b licensed pursuant to the provisions of the POWER
-R DEVICES
Contnctorb License Law(Chapter9(mmmenclog with Section 7DOO)of Divi- SWIMhBNG POOL ELECTRIC' -
O sion3ofthe Businessand Professions Code)or that he b exempt therefromand VALUATION
0 the bash for the alleged exemption. Any violation or Section 70315 by any OUTLETS-SWITCHES-FIXTURES
app0ant fore permit subjectstheappRcant to a civil penalty dna mare than
�AJ five hundred dollars($500).R CC NEW RESIDENTIAL ELECTR
❑I,as owner of the property,or my employers with wagon as their sok SQ.FT. STORIES TYPE CONSTRUCTION
compensation,tOkc. 0KH.ldothe work.f the
omCdureisone n&adIntended oroffered for
M Bale(Sec.7014,Buelneva ami Pro(esslons Cade The Contraciora License Uw
�$ does nor apply to an owner of property who Wilda or improves thereon,and OCC.GROUIs RES.UNITS
whodeessuchwork himeelf orthmwgh haownemployees,provided thatsuch
Improvements arc not Intended orortered for sale.If,however,thebuilding or TOTAL:
improvement.wldwilhlnomyearofcompletbn,rheowner-buBderwill have
the burden of proving that he did not Wild or improve for purpose ofeele.). QTY, PLUMBING PERMIT FEE
0 L cue owner of the property,am exclusively contracting with 11 ..d 1'100D 7ANE AIN
PERMIT ISSUANCE
contractors to construct the project(Sec.7054 Business and Professions Code:
The Contractor's License Taw does nn apply to an owner of property who ALTER-DRAIN VENT-WATER(EA)
Wilds or improves thereon,and who antra for such p(ajects with a
gp(rad. a)ucenead punuamrothe Ca rt.ctor�LKmxLaw. FEE SUMMARY
Ll BACK FLOW PROTECT.DEVICE
I am exempt under Sea B &P C for this... OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECEBrf M
WORKMANI bay..JS,LTION DECLARATION IV(TURES PER TRAP SCJ;OOL TAX Y N
❑I hereby fitorke that I have• l r cone or consent d pythemof or RFCmT M
3800 ateo(Worken'Compensatlonlmurana oracertifled.pytherco((Sec' GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,Iab CJ q
Po11ryM /W_ /OO�� / Z RECEJPFM
GAS IIA.SYSTEM-0VER 4(F.k)
Co������mppppppanv g - BUILDING DIVISION FEES
HCertlBed copy b hereby fumished. GREASEANDUS[RL WASTE INTERCEPTOR PLANCHECKFEE
Certified copy Is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA 71X1ET Date Recei [#
(This lecilon need not becompleted if the permit b torose hundred dollen
(f100)orlaa.) WATER HEATER W/VI2JT/ELECTR ENERGY FEE Y_ N_
I e rtifythst Lathe performance of thewark forwhich th.permit b Issued,
I shall not employ any person in any manner w as to become subject to the WATER SYSTEM/TRFATING PAID
Workera'CompenxOon Laws of Callfomla.Date
O Z Applicant NEW RESIDENTIAL PLMB._SQFT. Date Recei t#
Z D NOTICE TO APPLICANT.If,after nuking r his Certificate of Exemption,you
should become subject to the Worlsen'Compewtion provisions or the Labor TOTAL
N Code,you emod forthwith amply with such provisions orthb pernm shall beBUILDING FEE
i+
LU j deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE I
CL Iherebyaflrmthat there is a construction lending agency for the perfortry TOTAL: ELECTRIC FEE
:3Z an ce ottheworkforwhlchthbper tb Weed(Sec.3097,Civ.C.)
V Lander.Name PLUMBING FEE
IL F Lender.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icerti/ythatl terve readthis appRation and Asia thattheabove Information
1 ordinances f agree to comply with all city and county ordinanand nate laws PERMITISSUANCE FEES PAID:
>. N relating to Wilding coataction,and herebyauthorlu representativesofthb
H Z city to enter upon the above-mentioned property for inspection purposes, ALTER OR ADDTO MICH. Date Recei t#
L) — (We)agree .,ave,IndemN(y an d keep harmiess City of Cu Ino AIR HANDLING UNIT(TO 10,000 CFM)
agaiatlbb flee,o gmente,..... nses is may nary a ecru SUBTOTAL:
agalat.. Inco era.l m th pe it. /� AIRI-TANDLING UNIT(OVER IO,000CFM) CONSTRUCTION TAX
Sig u ( P nUCo ra r to EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
AZAR US MA ERIALS DIS LOSURE
Will the mit or Future building occupant store or hand le ha.ardous HEATING UNIT(TO I W,ODO BTI[) Date Recei t#
material..de0ned by the Cupertino Municipal Cod,Chapter 9,I$and the
Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yea No
Will the a pplica ret or lure building occvpa.t..a equl pmest or devices VENTILATION FAN(SINGLE RFSID) JSSWA{gE1DATE
mivu
which et hardous air. a
ntandnts as defined by the Bay Area Air IPf's A
alhy Meagemml Duhict7 BOILER-COMP OHI'OR 100,IXD BTTI)
Yn ❑n No 2 8 1992
have read the Fazarclousraferlals mqulrcmanhunderChapter6.95 of BOILER-COMP(OVER 100,0(10 B71p
the California Health&Safety Code,Sections 25505,8533 and 75534. 1 APR R
understand that if the building docs not currently haves re 4that It is my NEW RESIDEl-MAL MECA. SQ.FT.
morto 111 l nalfy the oavpant nb 1 must be t CII Y Ut tlUt'trj [FIV
prior. ofa Cedii=p.it pan Y/ ,/`lel/
Owl,or.oth agent ate TOTAL: ISSUEDBY�
OFFICE COPY