23383 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PLRMITNO.
BuOding Addre
23383
nets ams: one:NS:/ A — CITY OF CUPERTINO-BUILDING DIVISION
Con1ia°nr'aNem- LIc,No: APPLICATION /PERMIT
'��CIIA < BUILDING-ELECTRTCAI.PLUMBIN6-MECHANICAL CATEGORY C NTROL N
rcA1tM/Engineer. Llc N. 1 R
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ ❑ �I
LICENSED CONTRACTOR'S DECLARATION V1 El
I hereby afim,that lam licensed under p.Wons of Chapter9(aommen APPLIANCES-RESIDENTIAL j08 DESCRIPTIONIngwith Section 7m0)of Divudoa3oftWBuainesaand Profession Coxicand my
lice.Ie In full force and effect. PANELS
LuxD.tc Ctan Lk.N ��� Y�
Date CanfractorUP TO 2DOAhME
ARCM ITECT'S DECLARATION 201-1IX10 AMPS
�7 WT
I understand my plans shall be used as public records. OVER1000AMP5 - SQ.FT.FLOOR AREA $/SQ.FT.
D LED
Licensed Pmfessi cal SIGNSELECTRICAL
<6 OWNER-BUILDER DECLARATION
In a p, SPECIAL CIRCUIT/MISC
7f'v1566 mving rasormihatlam31.5,Bexempt usiness
ContractorsLice.law drthe
pO q (allowing reason.(Section 78315,Buslnm and Professions Code:Any tlty or
�Z :y countywhlchrequlresaper twmmtmdalter,bnprove,demalIsh,orrepair IEMP.METFR OR POLEINST.
3 enystmu mpriortoibi am:aalsomquknlheappU=tfumchperMtto POWER DEVICES AT
file a signed statement the he Is Hoen ant pursuant to the provisions of the ' y Gr
3 u.� Contractors License Law(Chapter 9(commencing with Section 700D)of Divi. SWIMMINCI'OOL ELECTRIC
s,�Os Won ofthe Business and Pro(embm Code)arthal he k man
exempt therefrod V'A A
the basis for the alleged exemption.'Any Violation of Section 7MIS by any OUTLETSSMTCHFSFIXTURES
applicant for a permit subjects the applicant to a civil penalty of not more than
live Hundred dollars%50a. NEWRESIDENTIALELECTit SQ.FI. STORIES TYPE CONSTRUCTION�n []Las owner of the property,or my employees with wages as their sok
compensatlon,widdo the work andthe structure Is not Intended or offered for
O sale(Sec 70K Bush ess ami Pedestal..Code:The Contractors License Law
does not apply to an owner of property who builds or Improves thereon,and OCC,GROUP REE.UMTS
who does such work himself or through Ms own employees,provided that such
improvements are nor Intended or offered for sale.It however,the building or TOTAL:
improvement Is sold within one yearofcompletion,the owner-builderwlll have
ft.Ilund an of proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE -
FLOODTDNE APN
4 as owner of the property,am exclusively Business
contracess and kg with s;Codd pBgMpp ISSUANCEcon
The Comrs to convect thew jectdoe(Seo apply
to nen and of property
Code:
The Coor impne License Law don not apply tct an owner of property who ALTER-DRAW&VENT-WATER(EA)
loullda or Imprensa 1pursua and who contracts (w each Injects with a FEE SUMMARY
'ffi or(s...mptlicensed
under antrothe Contratlols License Gen. BACK FLOW PROTECT,DEVICE
I_l I am exempt under Seo B&P C for this rescan
OUTSI DE FEES
DRAINS.FLOOR ROOF,AREA,CON I. SANITARY Y N
Owner Date RECENT Y
WORKMAN COMPENSATION DECLARATION
�I hereby dflrm that I have a certificate of consent to self-Insure,or FD(TURFS PER TRAP SCHOOLTAX Y_ N_RECEB'T N
certificate o(Worken'Compaustlan^lruuranceoracertlfkd copythereo!(Sec.
GAS.EA.ESYSTEM-1 INCA OUTLETS PARK FEE Y N
RFL®rl•N
GAS EA.SYSTEM-OVER d(EA)
Com BUILDING DIVISION FEES
Certified copy 6 herebyth the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy le(Ikd with the tlty lropMlon dlWelon.
CERTIFICATE OF IXEMPrION FROM WOR KERS' GREASE TRAP PAID
COMPENSATION INSURANCE y.EWER-BAAM.rARY-bTORM EA 20081. Date Remi tN
(This wction need not be completed lftFe pmmit Isfor one hundred dollars
(f10(fiorlen.) I WATER HEATER W/VENT/ELECTR ENERGYFEE Y N_
I mdlfythat In the performance of lhework forwhich this permit Is Issued,
I shall not employ any perwn In any manner so as to become subject to the WATER SYSTEM/TRFA77NTT .
Workeri Compensation Laws of Glffomk.Date PAID
—
Applicant
Z Applicant NEW RESIDENTIAL PLMB. SQ.Fr. Date Reml t#
Z O NOTICETO APPLICANT:If,ager maklomhIsCertificate provisions
of the
,you
Code, ou=becomasub)ectit the Workers'such pruatlan provhlunofthe Lobar TOTAL:
W N Code,you=atforthwithcomply with suchprovisbru or this permit shall be BUILDING W 7 deemed rtrvokN.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a G Ihercbyaorkfor w them IsaconWctssuion ldMec.309nry .C.) perform- TOTAL. 2 S0 ELECTRIC FEE
L) Z anceof the work for which this permltkLwed(Eec.3097,Civ.CJ La.�V
LL O lenders No PLUMBING FEE
LL F Ixnderb Addmn QrY.1 MECHANICAL PERMIT FEE MECHANICAL FEE
O W kcoImdlfythatl have read thkapplicationand statethat theaboveinfomention
IL rect.lagreelocomplywilh alltln
lyand cmuntyordinancand saE telaws PERMIT ISSUANCE FEES PAID:
relating to building construction,and hereby authorlae representatives of this
H N city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
Z Date Recei tic
V — (We)agree to save,ants,cindemnifyan d keepseeeehyppar d-h the City y ayam ro
againstliabilities,Cies,jMgmenb, Bend ezp%�.h mrmit. ywayaceroe AIR HA NOTING UNIT(TO 10,000 CFM) SUBTOTAL:
agairut sal Cltyin e ! gran ie permit
^� AIR HANDUNC T3Nrr rovFx lB,aacrkf) CONSTRUCTION TAX
S Tamm of Applicant/C tractor `7 Data EXHAUSTHOOD(W/DI1C1) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupantstore or handle haeardous HEATING UNIT(TO 100,ODO BTU) Date Reccei to
materlaI as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I lealth and Safety Code Section 25532(a)2 HEATING UNIT(OVER 10,000 BTU) TOTAL:
❑Yes No
Will the applies.or future building occupant use equipment or d evima VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit harardous aft contaml®rata as defined by the Bay Arca Air
•: Quality Management BOTLER-CAMPOMPOR100,000BTU) PAID
Y.4havcreadthehavar�iousomaterklsrequlrementsunderChapter6.95of BOILER-COMP(OVMIW,OWBTU) p�
the Calcrstlforok Health&Safety Code,Sections 25505,25533 and 25534.I AR 1992 .
and and that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. MAR 11
responsibility to notify the occupant of the requirements which must be mart
prior to Issuance of a Certificate of Occupancy.
Cid Y Uh 'UHtn4.RwW
Owner or aulhodaed agent Data - ISSOEDB Q
TOTAL:
OFFICE COPY