23156 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL P.OINT:PEN ONLY %
Building Project Identification - - PERMIT NO,
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Building Address: -J
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C: ✓ Tj4L 4- S
oe:
•nrsnSUBMITTAL
-73941/( 7 CITY OF CUPERTINO-BUILDING DIVISION . . `
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Contractor's Name: Lic,No: APPLICATION I PERMIT
/III;ah S Q's��tK' Se �a0 BUILDING-ELECTRICA4PLUMBINGMECHAMCAL CATEGORY CONTROL#
A.Mtect/Engineer. Lk.No: "
•QrY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address - "••. PUMTISSUANCE • ❑ ❑ ❑ • ,
, LICENSED CONTRACTOR'SDECLARATION
I hereby affirm that l am licensed under provisions of Cha r9(ccmonec APPLIANCES-RESIDENTIAL
Y p Pte .JOB DESCRIPTION
ingwithSectionin
7000)of d iotthe Bustnesaand Pro(essioneCade,and my
license bin full a pnd find.# / PANELS -
' License Clam O Llc# 7 3 O 7� -
Date O•. Contractor lN �/. 11fM5�� fit.OA /
ARCHITECTSDECLARATION / 201-1000 AMPS
ce0O I understand my plans shall be used a a public records. OVER1000AMPS F�.��.Lp�).1R N S/SQ.Fr.
µ❑� SIGNS ELECTRICAL . � ^� � � • �
Licensed Professional
• - P U T E R
GG i�C+�1 OWNEReBUILDERDECLARATION
.. SPECLILCE2CUIT/MIST
02 SS owing yssam.(hatIam exempt Contractor's License Law fort he
Op pp following reason.(Section tto Business and Professions Code:Any mp it
Cz�cy countywhkh requlreeapermlttommtmct,alter,bnprove,demolish,orrepalr TEMP.ME77RORPOLE]NST. /:� � ^
q'`'3 7 01
anystm=mprlortolbkeuamc akorequimstheappllcantforsuchp.r tto
ES ryG (�J file a signed statement that he is licensed pursuant m the provisions of the POWER DEVICES ^
Q6 3 w Contractor's License Taw(Chapter 9(mmmentlng with Section 7000)of Divi- '
Off^ sion 3 ofthe lkignessand Profeasimu Code)orthat he is emonpttherefromand SWO.IMING POOL ELECTRIC VALUATION
S the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHES-FIXNRES
< applicant for a permit subjects the applicant to a civil penalty of not more than
live hundredsowner
hepro NEW RESIDENTIAL ELFGTR_SQ.FT, ' STORIES ' TYPECONSIRUCTION
�, ❑I,as owner o!the property,or my employees with wages a there sole
compensation,K Business
work session structureisnot intended.,offered for
q
sale(Sec. pply to alnowand f property
Code:TheContraRotaLimns¢Law
-
whoa not apply to an owner of property who balms or Improves thereon,and OCC,GROUP , RES.(NITS
who doem ucheats am not mae dee.rough Msown e.If,ho es,provided theb ilding orhat such ,
improvements am not Intended earofredforsale.ILh er-builderwiH have TOTAL:
improvementiswldwlthlnone yearo(cwnpl&Ihn,theowner-bulMerwN have
ftIa1'rden of proving that he did rout build or Improve for purpose hfsale.). QTY, PLUMBING PERMIT FEE
L as owner of the property,am exclusively contracting with licensed FLOOD ZONE APN
L_I
contractors to construct the projed(Sec.7044,Business and Protesskru Code: PERMIT ISSUANCE _
The Contractor's License Law dues not apply to an owner of property who - ALTER-DRAIN&VENTWATER(EN `
builds or Improves thereon,and who contracts tar such plak -
cts with a PEE SUMMARY
't
cgpj[ador(a)licensed pursuant to the Contra&.,'.License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B&P C for this reason
OUTSIDE FEES
DRAINS-FLOOR,ROOF;AREA,COND. - SANITARY Y N
Owner Date - RECEIPT If
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N
❑I he affirm that I have a certificate of consent to self-insure,or a RECEIPT p
certificate at Worksm'Cmopemudcn Insurance ora certified copythereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N_
3800,Lab C. G p RECEIPT#
Policy# Q 2 7�S3 CS I GAS)FA.SYSTEM-OVER4(EA)
Com an� ^4� L' 'y 5 - BUILDING DIVISION FEES
MCerifled copy is herebyth the city CREASE/INDUSTRLWAS(EINTERCEPTOR PLANCHECK FEE
❑Certified mpyisfiled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE I
SEWER SANITARY STORM EA.2(IOFT. Date, Reuel tN
(This section need not be completed If the permit lefur me hundred dollars
($1000orless.) WATER HEATER W/VENT/m TR
ENERGY FEE Y N'
I certifythat lothe performance of thework forwhlch this permit is issued,
I shall not employ any person in any manner so in to become subject to the WATER SYSTEM/TREATING
Workers'Compematlan Laws of California.Date PAID
'0 Z Applicant' NEW RESIDENTIAL PLMB. SQFI. Date Recei tic
. Z O NOTICE TO APPLICANT:If,after raking this Ce&Ifles"Of Exemption,you
(• should become sub)ectt.the Workers'Compronti.n provisbruofthe Labor - TOTAL:
N Code,you=at forthwith comply with such provisions orthis permit shall be
WC deemed revoked. - SEI BUILDING E
d CONSTRUCTION LENDING AGENCY SEISMIC FEE
the affirmthat there is a mrutmction lending agency for the perform ELECTRIC FEE
Z once of the work for which this permit is ksued(Fee.3097,Civ.C.) - TOTAL:
- 0 O Lender.Name - PLUMBING FEE
LL 1= Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OI.eifythatIhavereadthisappRrationanddatethattheaboveinfom tion
O W iscorred.I agreeto complywlth all cityand county ordinances and nate laws PERMIT ISSUANCE ��^ FEES PAID: ' '
relating to building construction,and hereby authorize representatives of this
FN city to enter upon the abovcmemtioned property for Inspection purposes. - ALTER OR ADDIO MECH.
Z -
_ (We)agree to ave,Indemnify cogwstan d keep harmless the City of Cupertino Date Receiptil
against llab flea,rydgmenb, san pensee which may In anyway¢esus AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL•-
agalnsts City In cone n granting of this permit: AIRHANDLING UNIT(OVER I0,000CEM) CONSTRUCTION TAX "
tureof App ant/Contra&or Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or building occupant store or hand Is hazardous HEATING UNIT(TO 100,000 BTO) Date Recel tB
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the
Health and Safety Cade SeRlon 25531(a)? BATING UNIT(OVER 100,000 BTU) TOTAL:
.. 71Yes 1rr��i No'
WRlthe applicant or&tur.bulldi. occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants is defined by the Bay Area Air '
lity Management District? BORER-COMP(31-12OR 100,000 BTU) P. AID
4Yes F1 No
B
have read the haze ous materialsrequirementsunder Chapter 6.95 of BORER-COMf3t P(OV100,000 BTU)
the California Health&Safety Code,Sections 25505,75533 and 25534.1on -
respota t atlityto obey uilding the
of notcurrentlywhich
mostb met ' NEW RESIDENTIAL METH. - SQ.FT. JA14/ .O2 1Q('2
resp. Ility to notify the the occupant not curequiy have which must's¢met JAN �s77sv77
Prior uaror of Celli of Clamps ncy.
CITYWit II
neror auto zed agent Date - - - OT ISSUED BY:
OFFICE COPY