23540 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY r
Building Protect Identification PFJMT NO.
Building Address:
cone s Nante: one:
' CITY OF CUPERTINO-BUILDING DIVISION l ,
Contrator'e ante: Uc.C11rNaa.� APPLICATLON /PER IT ���'�'Z
U4' tOJ a].a7 BIRLDINGE,I]CTRICA4PLUMB] L CATEGORY CO t
Keor. Lk.No:
D esl6m. C CS ',X 76, QqY ELECTC E TT •EE BUILDING PERMIT INFO
Addreu zd. OIM I PERMTISSU 1C�1 1�/I
LICENSED CONTRACTOR'S DECLARATION
Iherebyaffirmthat l am licensed under provisions of Chapter 9(commenc- RESIDENTIA JOBDFSC ON
ingwith5en1on7000)ofDlvlslon3ofthe BusinessandProfessicesCode,and my �QO.�O' 1
Itcense le In fail form and effect. P 1`,l AI
License Clam - Lk.N
Date Contractor
11 ARCHITECTS DECLARATION 201-1000 AMPS
qna l understand my plea shag be used u public records. OVER 1000 AMPS - SQ.FT.FLDOR AREA $/SQ.FT.
q��uu cO
E z tj Licensed Professional SIGNSELECTRICAL r
�< OWNER-BUILDER DECLARATION SPECIAL CERCUI LSC rcmutyr,imp.� � TEMP.M ORPOLE Sf..
� countywhkh requireeapnrmit bcorawct,alter,improve,demolish,orrepalr
11 anystmdure prlarto Ba beuance,alsorequtmethe applicant forsuch permit toPOWEWCEq
K file a signed statement that he is licensed pursuant to the provislov a( the
3 u Contractor.License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
,_•�03 slon 3 ofthe Business and Profeniom Code)critter he iserempt therefrom and 1''�
�56p+ 6 the barb for the alleged exemption. Any violation of Section 70115 by any OUTLETSSWHC FLYCURP �q
O
applicant for apermit subjects the applicant toacivil penalty of net m n,than �tS6If
$ flue Lass owndoler
of thepr. NEW RESIDENTIAL ELECTR 5QFf. STORIES TYPECONSTRUCTION
❑T,a owner ll the a work a,or nd he employers with wages as their sole
7< mmparoutto,ec.70K Boomootted Prof.[..Code;
Contraintenctoroffered s
❑ sale(Sec. pply to an
dtproperty
Code:The Contactors License few
$
does not apply torn owner o(througywho nemplrlmprovnthereoryand
$^ whodaessuch work hlrrueBarthrough Neownemploycee,provided that such OCC.GROUP RFS I/NI75
improvernvnts are oh:
not Intended oroffered for s .If,howevegthebullding or
m
Improveentiesold within oneyearofmmplcuon,the owner-bullderwill have
t Men of proving that he did not build or Improve for purpose ofule.). QTy, PLUMBING PERMIT FEE FLCODZANE APN
Lj L as owner of the property,am exclusively contracting with licensed
mntmdoa to mmtmd the pmjed(Sm.70M,Businen and PMewtmu Code: PERMIT ISSUANCE
The Contractor's License Lew don not apply to an owner of property,who ALTER-DRAIN AVENT-WATER(EA)
Wilds or improves thereon,and who contracts for such ptojects with a vg)((actor(s)licensed pursuant to the Contractor's License Law. FEE SUMMARY
LJ I am exempt under See B k P C for this reason BACKFLOW PROTECT.DEVICE ro 11c,run st:.7c
1 Owner Date DRA[NS1lAOR ROOF,AREA,COND. —• SANITARY Y N_
RECEIPT
WORKMAN COMPENSATION OECIARATION FIXTURES PER TRAP SCHOOL TAX Y N
❑I he affirm that I have a certificate of consent to u141neurs,or a RECEET X
certificate of Worksre'Compematlon luurann are cartifled copythermf(Sac. GAS EA.SYSTEM-1 WCAOUTLETS �' PARKFEE Y N
3800,Lab C.) RECEPT M
Policy N GAS EA.SYSTEM-OVER 11EA)
Com any BUILOINODI VISION FEES
MCertified copy is hereby furnished. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKF
❑Certified ropy b filed withh the city impaction division. 1
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASETRAP PAID
COMPENSATION INSURANCE SEWERSANTTARYSIORM EA 2DOFT B Receipt s '^
(Thlsaectlon need not be completed H the permit is(Drove hundred dollars
(811 ordifethat in the performance ofthework forwItch this permit is boated,u.) wATERHFATRw/VENT/ELECTR77 ENERAXFEE Y
I shall not employ any person in any manner m u to become subJuct to the WATER SYSTEM/TREATING `L
Workers'Compensation laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SOFT. Date ecel w
Z NOTICE TO APPLICANT.If,after making this CenBlateof ExemplWn,you
1" should become subJuct to the Workers'Compensation provisions of the Labor TOTAL:
W Code,you must forthwith marplywlth such provision or this perrrdt shall BUILDINGTEEL
ILI > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
0. 0 Ihhereby afgrmthal there is a construction lending agency for the perform- TO ELECTRIC FEE -
an.of the work for which this permit b lasued(See.3097,Civ.C.)
00 LerderaN.. PLUMBING FEE
LL H Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icertifythatl have read this applicationand statethattheaboveinfor—it- �.
a Iscorrect.I agreeto comply with all city and county ordinances and slate laws PERMIT ISSUANCE t FEES PAID:
>. relating to building construction,and hereby authorize representatives of this
H N city to enter upon the above-mentioned property/w inspection purposes. C ALTER OR ADD TO MECH. d0
? (We)agree to save,Indemnify an'd keep harmless the City of Cu pedloo Dale Rxei [#
V
against liabilities,Judgments,occas and expenses which may in any way amus AIR HANDLING UNIT(TO 10,000 CPM) SUBTOTAL:
_Pga Id City to cora of the ptartlog of his permit CONSTRUCTION TAX
AIR]HANDLING[WIT(OVER t0,D00CIM)
gig o AppRa ZARDtndor a IXFHAUST HOOD(w/DUCT)
CONSTRUCTION TAX PAID: t
HAZARDOUS MATERIALS SOLOS RE '
it the applicant or future building oceupa t tore or handle hazardous HEATING UNIT CFO 100,000 BT U) 4 . D� Date Recei t#
rraterlal as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Flexlth and Safety Cod,e,Sedlon 2SS32(a)7 HEATING]IMT(OVER IDO,OOD BTU) IOTA
❑ Yes lsul No
Will the appliant tare building occupant use equipment or devices TVENTILATION FAN(SINGLE RESID) 9 IS 0 ISSUANCE DATE
which emit hazardous rlr contaminants as deRmd by the Bay Area Air
Quality Maregement t 7 BOILER-CAMP OHPOR 100,000 BTU) PAID
4Yrs No
haveaad the ealth see rCode,Se tequlre5505, 5533underaChapter.1 of BOILER-COMP(OVLR 100,000 BTU)
the
erstan t atifth bulidiy Code, currently have
a ternd2that it 'JUL_ 7 XT
understand that notify
the occupant
not the
haves hick that b busy NEW RESIDENTIAL MECH. SQFT. ` 1 V }(3^as
responsibility to ntity the ompant of the requirements which ovrst be reed /a7i/C
prior to issuance of a Certificate of Occupancy. CI �
Y Ur
Owner or authorlud agent Data ISSUED BI'
TO . E
OFFICE COPY
I -