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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Bulldin Pm'ed Identification
BuBding Addrenu
PFRMITNO.
23547
ossa, one:
APPILICA 11UN bUDMI I A
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
BUILDING-ELECTRICAL-PLUMBINGMECHANICAL
L�
dor. Na LIe.Nm
Arcliftect/Engfneer. Lk. No:
CA11fARY
CONTROLN
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Add.00Q/4-PERMITISSUANCEE]
❑ }�' ❑
L.�
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm thattaco licensed under provblona o(Cha)Ber9(rommen
[he ButlneuandPro/eseloneCode,andm
inense1Sectron 7000),dto.
license 1. 1. (Mali form andeffect.
APPLIANCES
JOB DESCRIPTION
.a �i P_�
R
V21,
PANELS
Limnse Cbea Llep
VL 1LI `v
Date Contractor
701.1000 AMPS
ARCHITECTS DECLARATION
I understand my plans shall be used u public records.
OVER 1000 AMPS -
SQ. FT. FLOOR AREA
$/SQ.Fr.
SIGNSELECTRICAL
Licensed ProfeeaLmal -
SPECIALCIRCU1T/MLSC
OWNER -BUILDER DECLARATION
I hereby affirmlhat I am exempt from the Contractor's License Law fm the
'
TEMP METER ORPOLE INST.
following... (Section 70313, Bwinessand Profeulooe Code.Anycilyor
county which requ Ince a permit to com[tud, alter, improve, demo Ibh, or repal r
anystmdure prior wits issuance, also requires the applicant for such permit to
file a signed statement that he Is licensed pursuant to the provisions of the
Contractors License Law (Chapter 9(commencing with Section 71100) of Divi.
Mona of the Business and Professions Code) or that he tat exempt therefrom and
]OWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
the bash for the alleged exemption. Any violation of Section 70314 by any
applicant for a permit subjecusthe applicant to a civil penalty of not room than
OUTLETSSWITCI{ESFIKfURES
-
llv61,aso.dredemideltathe property,
I, a• owner property, or my employees with wages Mere sole
NEW RESIDENTIAL ELECTR SQFr.
STORIES
TYPE CONSTRUCTION
com(Sec.7 on,K will of work, is
the etmcturebnot Intended. r
safe (Sec. aNeu and fersimnd coffered!.,
Business, Code: The ContractorsLicenseLaw
"
—
to
don oossu ly tork himself of who nem orlmprwvidedt at and
ot apply f property mat
whodocsMach workhimselfmlhrwgh his owne. such
OCC. GROUP
RES. UNITS
If,ho eprovhidedthe ildig or
Improvements ared with In one earofredfor Mah. the owevegffider, ill haw
Improverrenthwld withinoneyearufcompletlon,the owner-bu0derwill M1ave
TOTAL:
PLUMBING PERMIT FEE
the burden of proving that he did not build or improve for purpose of Mals.),
M L a• awns, of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Pmfesrlou Code:
QTY,
PERMIT ISSUANCE �.
FI.00DZONE-
APN
TTs Contractors License Law don not apply to an owner of property who
Wilda
ilda or Improve thereon, and who contracts for such ptojecs with a
cgpjpctor(•) licensed pursuant to the Conhactorb License Law.
LJ I am exempt under Sec B k P C for this rcuon
&VENT -WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS. FLOOR ROOF, AREA, COND.
SANITARY Y_ N_
RECEIPT a
Owner Data
WORK MAN COMPENSATION DECLARATION
❑I hereby affirm that I have • certificate of consent to sum
elf-Inre, a
ordift-m&Workeri Compensation insurance or. mrtifhd copy thereof(See.
3800, L.b C.)
FIXTURES PER TRAP
SCHOOL TAX Y_ N_
RECEIPT N
CAS FA. SYSTEM -1 INC40VTLETS
PARK FEE Y N
Policy p
RECEIPT 0
GAS F.A.SYSITM-0VER 6 (EA)
Com y
BUILDING DIVISION FEES
2Wed copy is hereby furnished.
Ce -Bled copy b pled with the city inspection division.
GREASE/INDUSfRL WASTE INTERCEPTOR
PLANCfiECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
SEWER-SANITARY-SIl7RM EA. 2WFT.
COMPENSATION INSURANCE
(TFI•sectionneed not becompleted lithe permit hfmomhundred dollars
Date Recti i#
WATFRHFATFRW/VENT/ELECT'R
ENERGY FEE Y N
(8100)., lana.)
Icertbess.) Nthe pc Aar[nanceofthework forwhlch [Ma pertnitls w„ed,
I shall not employ any person In any manner sou to become subject to the
Workers'Compeonatlon Laws of California. Date
WATER SYSTEM/TREATING
PAID
Applicant
NOTICNEW
APIaLIGNT: IL ager making this CertBicete al Exem)rtbn, you
should become subject to the Wo kers''Compewtion provisions of the Labor
Dale Remi t#
RESIDP-NTTAL PLMB. SQFr.
TOTAL:
Code, you must forthwith comply with such provinces orthb permit shall be
BUILDING ' EE
deemed revoked.
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hembyafRrmthAthere is acorstructlon lendingagency forthe perform-
arm of the work for which that permit b Issued (Sec. 3097, Civ. C.)
Lcrder. Name
Lendoes Address -
Icerti(ythat l havereadthls applimtionand statethattheabove Information
bcomect.I agree to comply withallcityand county ordinanms and state laws
TOA : �•
ELECTRIC FEE
PLUMBING FEE
OTY. MECHANICAL PERMIT FEE
MECHAMCAL FEE
PERMITISSUANCE
FEES PAID:
ecngtobuildingeo cdon, and hereby authorise representatives ofthb
roperty for Inspection purposes.
c t rater upon list ab&il�yamdk�.epharnde
IN agree to u im the City of Cupertinoa i liabilitis,N ensee whichmayinanywayaccrue
'
ALTER OR ADD TO MECH.
Date ROCei t#
AIR HANDLING UNIT CFO 10,000 CFM)
SUBTOTAL'
a saw Cityi rating of this permit.
•ya
AIR HANDLING UNIT (OVQt 10,000 CFM)
CONSTRUCCION TAX
torear pp /Con dor aseito
EXHAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HA RD US MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
,Dale Recel i#
Willtheappllrant or re building occupant store orhandle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.17, and the
Health and Safety Code Section 25532(a)?
RYes No
HEATING UNIT (OVER 100,000 BM
TOTAL:
as...
VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
illthe applicant or tore building ompant use equipment or device•
which emit hau rdoue air con[amim nts a• defined by the Bay Area Air
Quality Management District?
4RRe,q
Vee nnNo
Qp
P Le, 9 D
BOILER -COMP OHP OR 100,000 BM
BOILEILCOMP(OVER 100,000 BTT1)
have read thehazar�r.us materials requirements under Chapter 6.95 of
the Gllfemta Health 4 Safety Code,Sccd.. 25505, 75533 and 75534. 1
NEW RESIDENTIAL MECH. SQFTAPO
understand that lithe building dace not currently have a tenant, that it ix; my
responsibility to notify the ..part of the requirements which must be met
(�{y Iw
F19. �L
prior to issuance of a Certificate of Occupancy.
C�•^P'y�•r111YV
(SUED BY: �•!�i �I(,
-
Owneror authorized agent Date
TOTAL:
OFFICE COPY