23942 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO,
Building Address: - - 23942
19IpI- we¢T 5
wnen came5: one: A1= ,
W NR D A o -152--0IPB3 CITY OF CUPERTIN6BUILDING DIVISION
Contraaole Names: - .Lk.Na:
APPLICATION / PERMIT "
UST WF1'TEsg1S;tq BU[LDING-MFCTMCAIPLUMBING-MECHANICAL CATEGORY CONTROL#
Architect/Engineer. LIc.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address ❑ ❑ � ❑ i
I'FRhIITI55UANCE
LICENSED CONTRACTOR'S DECLARATION
•lwithS on7OOthat lamsi=3 d under ftheBui aonso(Caims9de,and e- APPLIANCESRESIDENTIAL JOB DESCRIPTION
imme i Sectfon force and
dieon3ofthe Buslnessand ProfeselonaCode,antl my
Liss se la In full force and effect. PANELS YA/
License Class L . t \"y► 1
Dare mummar3 USl W Nl'a R NEOZE¢ 1N
ARCHITECT'S DECLARATION 201-1000 AMPS
q�v $ I understand my phos eha6 be used as public records. OVER 1000 AMPS SQ:FT.FLOOR AREA $/SQ.Fr. .
k Licensed Professional SIGNS ELECTRICAL I...od
•
OWNER-BUILDER DECLARATION
�n a S['ECIAL CIItCU1T/M15C
t"Yl owing aurm thatiam31.5,B(romthed Profeor'sLicansessions
low fort he \ [ I
'Zo cmntyng reason.(Section 7031.5,Raciness and Profeaskna Code:Any city or s,,/ �•/ u`, G
�Z t.� TEMP.METER OR POLE INST.
countywhkh requires sissuace also trquirratheaprove,de rsuch orrepalr R
g any at rueturetatemeltehat he
lice sed pursuant t the forsuchpermite IYJNrER DEVICES TE /O '•
C1 file a actor's statement that he t r 9(card pursuant to the tion 70W) of the
ContractoleLkeaeLawChaper9(mmrenckgwithSe ion700)o(Dvl- SWIMMING POOL ELECTRIC i
ston3oflhe Buainemand Professlare Code)arthathehemmpttherefromand - - VALUATION -
y the bash for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS—SWITCHES-FIXTURES
pis applicant(oraper tsubjectstheappRcanttoadvllpemltyofnammthan
R five hundred dollars($500). NEW RESIDENTIAL ELEGTR
�n ❑I,as owner of the property, SQFI'. STORIES TYPE CONSTRUCTION
p will do the oul,a or my employes with wages r thele sok
compensation,Bilroth and rendthes Code: hes&IeteMedo License
Law
d for
O sale(Sec.7054,Business and Professions Code:The Contractor's Licerue Law
1 r3 g does not apply to an owner&property who Wilde or Improves thereon,and .CCC.GROUP RES UNITS
whodoessuchworkhimselforthreugh his own employees,provided thatsuch
improvements are n&Intended oroffered forcale.If,however,lhebuilding or TOTAL:
improvementisaad withlnomyearofcomplelion,the owner-builderwill have -
-
lhLI;urdmofprovingthathedidn&build or improve for purpose cleats.). QTY• PLUMBING PERMIT FEE FLOOD ZONE APN•
U L ae owner of the property,am exclusively contracting with licensed --T—
contractors to mrutmec ct the project(S7094,Business and Professions Code:
The Contractor's License Law does not apply to an owner a property whoALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon, p
and who contracts for ouch- (o)ects with a - FEE SUMMARY
15c� actoKa)hurried pursuant to the Contractor's License Law. - BACK FLOW PROTECT.DEVICE
I am exempt under Sea B&P C for this resaon
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_ ,
• Owner - Date re or a RECFRT#
WORKMANCOMPENSATIate air DECLARATION pIX.N �.I.�P SCHOOL TAX Y_ N_
QI M1ereby affirm that I terve a certlflcate of convent to wlf-inm RECEIPT
M
certl[Icate of Workers'Compensation Insurance or a certBled copy thereof(Ser GAS F.A.SYSTEM-1 INC.40UTLETS PARK FEE Y T
3 Policy
# C.7 RECEIPT#
Policy p GAS EA.SYSTEM-OVER 4(EA)
' Com any .� � BUILDING DIVISION FEES
ffCertlOed copy h hereby Wrnhhed. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
E]Certified mpy is filed with the city inspection divhion.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA?OOFC Date Recel t#
(This section need net be completed lithe permit is(or one hundred dollars
($100)Irle..) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
I mftifylhat In the performanceof the work forwhlch this permit is hoard,
I shall not employ any person In anymanner so as to become subject to the WATER SYSTEM/TREATING
Workere Compens&icn Laws of California.Date ,PAID
Z Z Applicant NEW RESIDENTIAL PLMB. SQ rr. Date Recei t#
Z O NOTICETO APPLICANT:If,after making this Certificate of Exemption,you
Fshould bemnn subject to the Workers''Compematlon provisions of the Labor TOTAL:
Code,you at forthwith comply with such provisions or this permit shall be
W > deemed revoked. BUILDING FEE
CL C "CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a corutmctlon lending agency forthe perform- !
ELECTRICFEE
D Z once oflhe work(orwhlch thin permit is hsued(Sec.3097,Civ.C.)
U2 Lenders Name PLUMBING FEE
end
LL'~ LereAddress QTY. MECHANICALPERMIT 'FEE MECHANICAL FEE
U I mrtifythatl have read this apploationand statethethe above information
O W Iscored.I agree to comply with all cityand county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} N relating to building construction,and hereby amda
hoe representatives of this
j. city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
2 (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
V against liabilities,jacigmenh,mks and expenses which may in anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City In consequence of the granting of this it - -
\ Q74AAA AIR HANDLING UNIT(OVER IO,ODOCFM) CONSTRUCTIONTAX
signs of AppBcant/Contactor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recel t#
material as defined by the Cupertino Muriclpal Code,Chapter 9.1$.and the -
I lealth and Safety Coda Section 25532(a)7 HEATING UNIT(OVER 10i"BTU) TOTAL:
RYea No
ill the applicant curtare building occupant use equipment or devices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
Mich emit havardous air contaminants as defined by the Bay Area Air
� p�#
Ilty Management District? BOILER-COMPQHPOR100,000BTU) P A ! D
�j Yn ❑No
(have read the hazaMous materials requirements under Chapter6.95 of BOILER-COMP(OVER100,000 BTU)
the California Health&SafetyCode,Sections 25505,25533 and 25534.I JUL _7 ���
understand that ifthe building does not currently have a tenant,that it h my NEW RESIDENTIAL MECH. SQ.FF.
responsibility to net lfy the occupant of the requirements which most be met
prior to issuance of a Certificate of Occupancy.
Ow oror aut�n l5am ISSUED BY:
' TOTAL:
OFFICE COPY