23638 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Peaectldentlficatim, I PERMIT NO.
Bnnaing nacre,,: 23638
/O C ASS L
ne el
>� ::rw�- '� 1 e. CITY OF CUPERTINO-BUILDING DIVISION
. C.^Mr,ah�r.Name: LIe. APPLICATION / PERMIT
{fin 1_ �L7N�K 5N75�y7- BUILDING-ELECTMCALML BINGMECfI NICA CATEGORY CONTROL
Amnaed/F�Rlpeer. Lf— k.No.
�A QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addreu
PERMITISSUANCE 1:1 El El
CONTRACTOR'S DECLARATION
I hereby affirm that lam licensed under provisions of Chapter9(comment APPLIANCESRESIDENTIAL JOB DESCRIPTION
IngwithSection 7000)OMIvislon3ofthe BusinessandProfesslonaCode,and my ///���
It..la in full in and dfect �// PANES �� \ T , a `„ `Q O--<�
LIcen;IC m Co N J �'<J Y7 lL.)
Date Contractor
ARCHITECT'S DECLARATION 201-1000AMPS -
fQgotOZp ]understand my pbnsshal be used epubOc recoNs OVER 1000 AMPS SQ.FT.FLOOR AREA f/SQ.FT.
E o(/ Licensed Professiorul SIGNS ELECTRICAL
G< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
Z l.., Iherebyaffirm that l am exempt fromthe Contractor's License Law forthe
following-we.(Section 7031.5,Business and Professions Code:My city or
i"', county which requbes a permit to rormtrud,alter,Improve,demolish,or repair IFAtP.ME[ER ORIOLE INST.
a anystm=mpdortoitsiswance,alsorequim,theappliuntforeuchpermltto
rN1 file a signed statement that he B licensed pursuant to the provleons of the POWER DEVICES
O O
Contractor's License Taw(Chapter 9(commencing with Section 7000)of Divl-
3 sion3ofthe Businessand Pwfmss .0 de)arthathebemmpttherefromand SWIMMING FOOL ELECTRIC VALUATION
el: 5 the basis for the alleged exemption. My violation of Section MIS by any �O O
applicant fora permit subjects the applicant loacivil pethan OUTLE'ISSWITCHFSEXI'URES
penalty of one more
0 Eve hundred dolbrs(¢S0M.
I^n ❑I,as owner of the NEW RESIDENTIAL ELECTR SQFr. STORIES TYPECONSIRUCTION
ework,aormy employees as theledfo
compensation,Buldotheworkandthes Code:
dureh net Intended or offered for
O Bonnet appy Business owner
ofpropProcaerty
Co builds Contractors License Law
'$ docs net apply to an owner o(propeny who builds orlmprovea thereon and OCC.GROUT' RFS.UNITS
wheel. suchworkhimssiforthwghhisownemploye,,providedthatwrh
bnprovements are not Intended or offered for sale.If,however,the building or TOTAL:
Improvement bwIdwlthln omyearofcompldion,the owner.builderwlll have
the burden of proving that he did not build or improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
[:]L as owner of the property,am exclusively contracting with licensed PQtMl;I,1.S5UANCE
contractor,to construct the project(See.70K Business and Professions Code:
The Contras ues License Law dm not apply to an owner of property who ALTER-DRAM N:VENT-WATER(EM
or improves thereon,and who contracts for such peppers with a
Tado,(.)Ilcensedpu..set to the Contractor'.License Law. FEE SUMMARY
Tri am exempt under Sec w
B k TP C for this rean BACK FLOW PROTECT.DEVICE OUTSIDE FEES
•
DRAINS FLOOR ROOF,AREA,CONED. SANITARY Y N Owner Data RFGEBTN
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a can iBate of consent to self-Insure,or a FIXTURES PER TRAP SCITOOL TAX Y N
GAS EA.SYSTEM
.1
aLab
CJ of Workers Compensation lnsuranaaacenifled copy thereof 6RECEPI'N
ec. .1 ING4 OUTLET'S PARK FEE Y N
Policy
_
eiicy N RECEIPT M
Cam an GAS-EA.SYSTEM-0VER4(FA) BUILDING DI VISION FEES
-
dl(ledcopy hhereby furnlshed.d. LA
GREASE./INDUSIRL WASTE INTERCEPTOR
PNCHECK.FEE
ertlfird copy B filed with the city Inspection division.
CERTIFICATE OF MEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATIONINSURANCE SEWER-SANITARY-STORM EA.2006-T. Date RCCY'1 t#
Rhisaectlon need red be
COMPENSATION
lithe permit is(Drone hundreddollars
01100)mlassJ WATER HEATER W/VENT/E.ECTR ENERGY FEE Y N
I artifythat In the perform
performance ofthework forwhlch this permit is issued,
I shall not employ any person In any restorer an as to become subjett to the WATER SYSIEMt/TREATING
Workers'Compensation laws of California.Date PAID
O Z NOEICApplicant NEW RESIDENTIAL PLMB. SQJrT. Date Re I IN
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
in Code,you moat forthwith comply with such provisions orthb permit shall be
LI.I > deemed revoked. BU
CL C CONSTRUCTION LENDING AGENCY - SEISMIC FEE
I hereby affirm that there is a cowtwdton lending agency for the pedoren ELECTRIC FEE
L) Z ance w
of the work for which this permit h lsed(See 3097,Civ.CJ TOTAL:
U O Lenders Name PLUMBING FEE
IL F I.ed&aAddress QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Imrify that]have readthhappliaov
lionand datelhattheabe information
bmrred.I agree tocomply with all city and county ordinances and date laws PERMIT ISSUANCE FEES PAID:
).
Z W relating tobullding construction,and hereby Authorize representative ofthb
H city to enter upon the above-mentknrd property for Impaction purposes. ALTER OR ADD TO MECH. Date Recei tic
— (We)agree to save,Indemnify an d keep harmless the City of Cu Fenton P
agahathabllitle,pdgments,co .end expenses which may In anywayacerm AIRHANDLING UNIT(TO 10,ODOCPW SUBTOTAL:
zgalnstseidC it n sten fthc granting thbpe
q MR HANDLING UNIT(OVER lgaooCFM) CONSTRUCTION TAX
Signstureo(A p ant/Con odor to DcliAUS'T HOOD(W/DI1CT) CONSTRUCTION TAX PAID:
HAZA RDOUS MATERIALS DI S SUR
Will the a ppllunt or future building occupant at..or hand le haeml..s HEATING UNIT(TO I OD,000 BTO) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
Health and Safety Code Section 2S532(a)7 HEATING UNIT(OVER 100,000 B'T'U) TOTAL:
QYe I NN.
Bl the appOant or future bulleing occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit harardouf air contaminants as defined by the Bay Area Air pp
• ality Management Dbtdd7 - BOILER-COMP(311P OR 100,D(IO BTU) A
Ya ❑❑No �Q
haveread the haaardous materials requirerrcnts under Chapter 6.95 of BOIMR-COMP(OVER 100,000 BTU) 17171A
1 _�
the California Health k Safety Code,Sections 25505,25533 and 25534, 1 N 'fA(]as
understand that lithe building does not ourrontly have a tenant,that It b my NEW RESIDENTIAL MECH. SQ.FT. 1s7s7C
rosporvlbllity to notify the occupant of the requirements which moat be met CITY
prior to issuance of a Certificate ofOccupancy. U/-
wrcn ulvv
Owner or aulhorlud agent Date ISSUEDBY: 'o&_t
TOTAL:
OFFICE COPY