23024 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL-POINT PEN ONLY
Buildinx Project Identification PERMIT NO.
Building Addreas:
23024
Z 30w��5 was
nen .�.�n one
CITY OF CUPERTINO-BUILDING DIVISIONsr
. Co tractor'sNamc; Qo: APPLICATION / PERMIT
L
aBUILDINGELECTRICALPLIIMBING-MFGHAMCAL CATEGORY CONTROL It
Architect/Engineer. Lk.Na:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ �" ❑ ❑
LICENSED CONTRACTOR'S DECLARATION JOB
Ihereby Sechon70Mmlamlhmsedunderprovitlonsofmiana9(mmmen APPLIANCES-RESIDENTIAL JOB DESCRIPTION
iogwi11...hSeMan force ofdafect. afthegu0neaand ProfenlaneCadeand my
Lt.oseCli.
b 1.li WB force and k,If PANELS
Limen Clan LILY I ,
Date Comranor UP TO 200AH!S
ARCHITECT'S DECLARATION 201-IODDAMPS
q�q�uu orOp ZIunderstand my plans shall be used u public records, OVERl000AMPS SQ.FF.FLOOR AREA S/SQ.FT.
k
Lime ed Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION
IJn SPF.CIALCIRCUIT/MISC
z1.., Ihcrebyaffltnthatl amexempt fromlhe Contractor's Lircnn Law for the _
O�
following reason.(SecOon 70'315,Bu.inen and Professions Code:Any city or•" TEMP.METER OR POLE MSI.
cnantywhimpr rltolft rmBtomot-qui sibeaprovedemmch, er ttr
gq 6 any.signerep0ement hatheis,thanse pursuant
ro such of to POWER DEVICES
fie a signed statement that he V Ilrensed pursuant to the proWions of the
OE q Contractor.License Law(Chapter9(commencing with Section 7000)of Divi- EWrMVgNCRDOLELECTRIC VALUATION
ei..3.fth,Husinessend Professions Code).,lh4 hebeumpttherefromand
Q the basis for the alleged exemption. Any violation of Secilon 70315 by"
y OUTLETSSWITCHFSFTXTURES
applicant(Ora permit subjeMthe applicant to a civil penalty of nor more tMn
$
five hundred dollars(SS00).
❑I,as owner of the property,or my employees with wages as theirsoe NEW RESIDENTIAL ELGCIR SQ'Fr' STORIES TYPECONSTRUCTION
compensation,will do the work,and the structure is not intended or offered for
O .In(Sec.7044,Business and Professions Code:The Contractors Llmnse Taw
$ does not apply to an owner of property who builds or irnpm,cs thereon.and OCC GROUP RES UNITS
who does such work hlmaeUorthmugh his own employees,provided that such
Improvements are not Intended orolfered forsale.If,however,thebuildtng or TOT
improvement bsold withinomyearofcomnpldbRtheowner-bu0derwBl have
ttaknrden of proving that he did not build or improve for purpose of sale,). QTY. PLUMBING PERMIT FEE
L� FLOOD ZONE APN
L as owner tr the property,em.7044 Buselyiness
contracess and Ing with Ilmnsed PERMITISSUANCE
mntrators to construct the project(Sec.7044 Business end Professions Code:
The Contractor's License Law does not apply to an owner of property who pL779(-DRAM&VENT-WATER EEA)
builds or Improves thereon, and who mmnete for such pt peat with a FEE SUMMARY
cgiLt actm(s)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
LI I am exempt under Sec B&P C for this moon
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
. Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAX Y N
❑l hereby orke that I have o lrtura to of consent to nlf-Inerao ora RECEIPT N
m00,L.bofWorkers'Compewtlanlnsuranm ora arti(led mpythereof(Sec. CAS EA.SYSTEM-I INCA OUTLETS PARK Y N
3HOQ Lb C.) RECEl'I p
Policy N GAS FA.SYSTEM.OA)VER 4(E
m any BUILDING DIVISION FEES
Certified copy is;hereby furnished.
thcity
e city ty
Certified copy V filed with
Inspection divlalon.
GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑ th
CERTIFICATE OF EXEMPTION FROM WORKERS' GREA-SBTRAP PAID
COMPENSATION INSURANCE SEWER SANITARY STORM EA 200FT Date Recef t#
(Those tion need not be completed ifthe permit a fm ons hundred dollars
(St 1 cemlyth) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
Imrtifythat In the performance oHheworklor which this nN11e
shall not employ any en uny runner n sub), he WATERSYSITM/TREATING
orlicam yips of C. �ornh.D�4 PAID
O Z PHTCEt s/ca/ NEW RESIDENTIAL PLMB. SQ.Ff. Date Remi t#
I.
Z NOTICE70 PLII eaorr oWdogker'Com aiflprovi provisions
,you
ehmvid become subject to the Workers'Compensation provisions of the Labor TOTAL:
t N Code,you moat forthwith comply with such provisions orthla permit shall be BD
ILDING FEE
W 9 deemed revoked.
CL o CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyaffirmthxt there V a construction lending agency for the perform TOTAL: ELECTRIC FEE ,
Z anm ofthe work forwhichihb permit O lnued(Sec.3097,Civ.C.)
a2 Landers Name - PLUMBING FEE
LL F Lender.Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Imdifyihatlluvereadthaapplmtionandetatethattheabovelnformation
IL 0mt
rm .l agreeto cornD:
plywith all cityand county ordinances and statelaava PERMIT ISSUANCE FEES PAI
W relating to building construction,and hereby authorize representativesof this _
F Z city to enter upon the above�rmrtloned property for inspection purpose. ALTERORADDTOMECH. Dafe Receipt#
_ (We)agree to save,Indemnify an d keep ha an the City of Cu perils.
against ludilities,' sand expen may waya.e AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL:
ago Last.. n ..of the gof this CONSTRUCTION TAX
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of App cant/Contrstmt EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicant or future building occup.nt.t.,e.r handle hazardous HEATING UNIT CIO I00,0D0 BTU) Date Recei t#
material as defined by the Cupertino Municipal Cade,Chapter9.12 and the
I❑ Yeand Safety Cade,Sedum 532(a)I HEATING UNIT(OVER 100,000 BTU) TOTA . -1
No
Will the applicant or❑future building occupant un equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANS DATE -
which emir hazardomair mntaminantsasd¢find by the Bay Area Air G ' �7
Qua llty Management District? HOLLER-COMP OHP OR 100,000 BTU) P /1
Y s ❑No
I have read tM1e hazardnn,rtulerlaLs requirerrenb underChapter 6.95 of BOILER-COMP(OVIX 100,00)BTU) 25 1991
the Callfornb Health&SafetyC d1,Sections 25505,25533 and 25S34. 1 6IOV
understand that if the bullellog dura not currently have a tenant,that It is my NEW RESIDENTIAL MECH. 5QFF IVV /\��`.���}�/)
responsibility to notlfy the occupant of the requirements which most he met r1
prior to issuance of a Certificate of Occupancy. CITY Ur CUFtN111WJ `/
V as,,��rk�..a.�� ��aass ��s��
Ownerorauthodzndagsm Date ISSUEDBY Fr4vrs�t0
TOTAL:
OFFICE COPY