23713APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE.BALL POINT PEN ONLY
Building Project Identification
Building Address:
PERMITNO.
1
b3 3 �3
23713
wners erre \ onr.
S '2. OLCM'
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDINGELECnUCALPLUMBINGMECHAMCAL
A
i L—lJ
coraaactor's No:
G
CATEGORY
CONTROL#
Architect Englrteer. No:
"1' 6's
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
-
Address
PFRMITISSUANCE -
LICF.NSED CONTRACTOR'S DECLARATION
I hereby of Chapter
ectionmthat i Division ftheunder Bupessandsaf CsumnsC(commmc
Ing with In fon force of Divifect. the BuclressandPro(es.loneCade,and my
Iicenseblt. force and effect.
Cb® LIC #
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
/�A _ `
1P Rv3
-
PANELSLt.-
Date
Dale Contractor
UPT02DOAM-
701-1000 AMPS
• ARCHITECT'S DECLARATION
I understand my plans shall be used as public records
OVER 1000 AMPS
SQ. FT. FLOOR AREA
S/SQ. FT.
SIGNSELECTRICAL
Licensed Professional
SPECIALCIRCUIT/MLSC
OWNER -BUILDER DECLARATION
I herebyaf ime that I am exempt (ram the Contratorb License Law for the
TEMP. METER OR POLE INSr.
following reason.(Sectim 7031.5, Business and Professions Code: Any city or
county which requires a permit tomrutruct, alter, improve, demolish, orrepair
any nructurepdortolts Issuance,alaorequiresthe applicant for such perndtto
file a signed statement that he is licensed pursuant to the provisions of the
POWER DEVICES
SWIMMING POOL ELECTRIC
Contracors License Law (Chapter 9(commending with Section 7000) of DWI-
elon3 olthe Bualneasand ProfxgWmCode) orthat he is exempttherefromand
VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant for a permit subjects the applicant to a civil penalty of not more than
OUILE7SSWITCHFSFI%7VRES
ANEWundred dollars (5500.
I, as owner of the property, or my employees with wages as their wk
RESDENTIAL ELECTR SQ.FP.
STORIES
TYPE CONSTRUCTION
rompensaHm, will do the work and the structure is not Intended or offered for
sale (Sec. 70K Business and Profembw Code: The Contractors License Law
does not apply to an owner of property who build, or Improves thereon, and
who doessuchwork himself or through hismen employees, provided that such
OCC.GROUP
RFS. UNITS
improvements, arc not Intended oroffered for sale. If, howevep thebuilding or
Improvement beold wlthNomyearo(complet mtheowner-bu0derwill have
t)Wkuden of proving that he did not build or improve for purpose of sate.).
LI 4 as owner of the property, am exclusively Businessand ing with licensed
contractors; to construct the project (Sec. 904y end ons Code:
Qty, PLUMBING PERMIT FEE
FLOOD ZONE
APN
PERMIT ISSUANCE
The .,impContractor's License Lw does not apply tom owner d property who
to sus of pro
buRda or improves thveom and who msdoes for such piojm with a
pursuant to the Cmerectars License Law.
�p(r!ct m exempt
LJ I am exempt under Sec. B & P C for fhb reason
ALTER -DRAIN& VEM-WATER (EN
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y N
RECEIPT #
Owner Date
WORKMAN COMPENSATION DECLARATION
Of hereby affirm,ve that [ha • ceflawsrc
klte a( consent to self -h, ora
certlRcateofWmIxers Camperastim lnsurence.. acertl(ledeopythromf(Sec.
3800, Lab C.)
Policy
pDCTURFS. PER TRAP
SCI100L TA% Y
NRFCmPT #
GAS EA. SYSTEM -1 INC#OUTILETS
PARK FEE Y N
RECEIPT #
p
m any
GAS EA. SYSTEM -OVER # IEA)
BUILDING DIVISION FEES '
Certified copy Is hereby tumecity
CedNed copy b (fled with the city Inspection division.
CREVSEANDUSRL WASTE INTERCEPTOR
PLANCHECKFEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
SEWER -SANITARY -STORM EA 700FT
COMPENSATION INSURANCE
(This section need not be completed Ifthe permit is fecone hundred dollars
Date ReWi t#
WATER HEATER w/vFNT/F].ECTR
ENERGYFEE Y_ N
($100)mless.)
I certify that In the performance of the work for which this permit is Issued,
WATER SYSTEM/TREATING
1 shall not employ any person In any manner so oto become subject m the
Workcrn Compensation Laws of California. Date
PAID
Applicant
NOTICETO APPLICANT. If, after making this Certlflote of Eaemptim, you
should become subject to the Workers'Compeoation provisions of the Labor
NEW RESIDENTIAL PLMB. SQFI'.
Date Recti tN
TOTAL:
BUILDING
Code, you moat forthwith comply with such provisions orthes permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
-
SEISMIC FEE
Iherebyaflthat there is a constructim[ending agency forthe perform
.(the work for which this permit b issued f Tec. 3097, Civ. C.)
Lender's Name
Lando. Address
I cenlfythat I have road thlsapplicatlanand idatethatthe above Information
banned. I agree to comply with all cityand county ordinances and state law.
TOTAL
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMUIRSUANCE
FEES PAID:
relating to building construction, and hereby authadu mpresentatWesof this
city to enter upon the above-mentioreed property for inspection purpose,
(We) agree to save, indemnify an d keep harmless the City of Cuperttoo
against llabNtles,jrdgments: costaand ezpenreawhich may In anywayaccrue
ALTERORADDTOMECH.
Date Reeel tN
AIRHANDLING UNIT TTO 10,000CFM)
SUBTOTAL:
against said City in eousequmce oftha granting of this permit.
AIR HANDLING UNIT (OVER. 1o,(oocEst)
CONSTRUCTION TAX
. gnature of Applicant/Contractor Date
EXHAUSTHOODCW/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant atom or handle havrdous
material as defined by the Cupertino Municipal Code, Chapter 9.13, and the
Health and Safety Code Section 25S3IG)t
❑ Yea L_I No
BEATING UNIT (TO 100,000 BTU)
Date Recei NI
HEATING UNIT (OVER 100,000 BTU)
TO
VENTILATION PAN (SINGLE RESID)
ISSUANCE DATE
WIII the applicant orftturebuildingoccupant useequipmentmdevicea
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District?
4Yes No
PAID
BOILER -COMP DHT OR 100,DW BTU)
BO LER-COMP (OVER 100,D00 BTU
have ad the ls of
Sectequl 25505, 5533undanhapter6.95
kSafety Code, Sections75515,ve. tenant, ,that I
laHeath&Safety Code,
the Ghandthat
at if the
understand thatn tify the ing doesoccupant of t eroquire ase; whichflat It bay
responsibility to notify the occupant of the mqulrcmenb which must be and
- MAY 27
NEW RESIDENTIAL MECH. 'SQ.Ff
prior tot wnceofa Certificated Occupancy.
I
CI i Vi LI CTlf 11 st,/
ISSUED BY:
Owner or authorized agent Data
TOTAL:
OFFICE COPY