23027APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pru en Identification
Building Addmev:
PFR.wT NO.
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION /PERMIT
i
tract '.N.me, I.Ic.No:
CATEGC)RY
CONTROL
AmhltMBUILDINGdECIRKA41'LIIMBINGMECHANIC.k1.
Lfr. N. '
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Nth ❑
inIFertby.flinn
Add.
PERMIT ISSUANCE
LICENSED CONTRACTOR -S DECLARATION
that lam lkemueduMerpmvWmso(Chapter9 (oorrvmen
ingwlth5ectbn7OW)ofDM m3ofthe Budnean,nd Profs ..Cade,,nd
11¢nex, is In full froand effort. I V //(�.
!o
APPLIANCES -RESIDENTIAL
0 N
T M�
PANELS
Li¢nx cls. Lle.. / /
ah Contnctor�
201.1000 AMPS
ARCHITECTS DECLARATION
I uMsrod my phmsha Bhe used a public teootd>
JOVER1000AMPS
SQ. FT. FLOOR AREA
$/SQ. F7.
SIGNS ELECTRICAL �
Llarieed l'roleabwl
OWNER -BUILDER DECLARATION
I hercbyalflrm that I am exempt !corn the C-mractorLI¢ve Law (¢the
's
9' EOALCIRCUIT/MIST /.
TEMP. hTBJT]t ORIOLE WST. _(_)I�/I
f -Bowing ... (Sa uo 7m15, fuslnea and Profmbn Code: Any city or
mrnrywhkh rcqukva pemd mmrotruet, alter, Improve, demolbh,ortepalr
�1IJ "� I'
I�
myatmcturt pd¢to ib imuarc<,abo mequisetheappkant(¢such permit to
(Ile . signed statement that he b Ilaraed purnunt to the provbbru of the
BOWER DEVICES
-
SWIMMING IDOL ELECTRIC
C.Mract.e. Llceme law (Chapmr 9 (commeneing with Scone m 7000) of DIN-
ni-n3of the Buelnm and Pmfenbro Code)Or N.t bets exeorytthetelromand
LUATI I•f��
the hash for the alleged exemptlor. My vialsibn of Senbn 70315 by any
app0ont fora permit subjects the applIcant to. civil penalty of not motethan
Ove hundred dollar (1.500!.
❑ I, u owner of the property, or my employer with wages u thele sole
OUTLETS- 60
s '
NEW RESIDENTIAL ElECTR SQ.FI'.
STORIES
TYPE CONSTRUCTION
mmpenaatlm, will do the work and the A ctum b not wended or offend for
vle (Se. 70K Buaircae and Pro(mbns Code: The CormaRots LA.. Law
-
docs not apply to an owner of property who build. or improves thenen, and
who doosueh work hlmseU or through his own employees, provided that such
OCC. GROUP
RLS TINCTS
Improveme armor Intendedor-Hemi!¢silk. ILhowever,thebuildinger
Mprovemerdbsob withinorchearo(campleibretheovner-WBderwlll have
TOT
tlurd<n ofpm.•Ing that he dm ri-tis-ud-r i,npm.•e fww-f�J
L I L as owner of the property, .m eeclwivety mWntracg with seemed
mntractaato comiroctthe project (See 7051, Buelnm.rd Proleabru Code:
QTY. PLUMBING PERMIT FEE-
PERMIT ISSUANCE
F10DD ZONE
APN
The Contrscior: Licensee Law don not apply to an owner N property who
Wild. r Improv thneon, and who mmdraeta r¢ such p(ojects with a
0�ftaCtor(s) 11cenned pursuant to the Cmtr.nals License Law.
LJ I am exempt under Sec B & P C for this renin
�� DRAIN & VENT -WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSI UP FEES
IX(AINSF R,.ROOF, AREA, GOND.
SANITARY Y N_
RECmrT
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a mrtiRate of content to seU-Irwme, ¢ a
¢rtUiara of Warkari Cwnpenesilmlrcunn¢ ma ¢rt1f4•d appy lhemof f5ee
mcil' ab C.)
FD(TTEPER TRAP
I�S
C K O.7AX Y_ N_
RST 1
GAS E.A. SYSTEM -1 INCL OVITEIS
PARK FEE Y_ N_
Py(cy. R
RECmT If
GAS E&SYSTT11-0VER4(EA)
Co ny
BUILDING DIVISION FEES
CertlflN copy Is hereby fumlehed.
Certified ropy is liked with the ctb Impectbn divinim.
GREASE/WDUSTRLWASIEINIERCbTOR
PLANCHECKFLE
CREASE TRAP
CERTIFICATE OF U DATION FROM WORKERS'
PAID
SEWF3LSANITAAY-STORM FA 20(F7.Date
COMPENSATION INSURANCE
(Chia senbn need rat be completed Uthe permit b fo one hundrN dokan
RCCei L#
WATER HEATER w/vFxr/EIEcrR
ENERGY FEE Y N_
(5100)¢1.).
I certify that b rr¢ tithe the perfoanwork missued,for which this pedt Is issued,
I shall not employ any person In any manner m to to become subject to the
W-rkera Compemanon Laws of C.Iff¢nia. Date
WATER SYSIT91/TREATING
PAID
Applicant
NEW RESIDENTIAL PLMB. SQF7.
Date Reael t#
NOTICE TO APPLICANT: If, after making this Cerfik,ate of Exemption, you
should become subject to the Workers' Compewtbn provbbro of the Labor
TO'T'AL:
Code, you m.mt forthwith comply with such pnovbbru or Nis permit shall be
BUILQINC
dermed revoked.
5EISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that then Ism construction lending.genry for the perform
.nm of the work for which this permit b binned (Sec W, Civ. C)
Lender: N.m a
IeMeri Addrta.
I ¢dlfythat T lave rt,d thb.ppliatbn,rd eutethat Ihe.bove Information
tsmrmxd.laSteerocomplywRhaBtlty.Nmuntyordinunm,nd sista laws
TOTAL:
ELECTRIC FEE
L
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE*
MECHANICAL FEE
PERMIT ISSUANCE '�
FEF; PAID:
rNatl ng to building mrtftroction,ami hereby authorise repreaent,U o(thb
soy toente nthe .hove-nr ft ropedy(Or bepedbn purpose.
(We) move,iMa -(y,n ph.rMer the City of Cupertino
Date .Reed t#
ALTFRORADDTOMDaL
SUBTOTAL•
egaw Lbt ,jrdgme a pe�swhkeh yinanywayaccrue
seg, Id In cin nting ort mit��_
suture or Applia t or D,te
AIR HANDING UNTT CN 10,000 cm
AIRHA NGUNIT(OVER IQ"CFM)
CONSTRUCTION TAX '
EXHnusTHOCID(W/DUCT)
CONSTRUCTION TAX PAID:
HAl RDOUS MATERIALS Of OSURE
HFAIING UNIT(TO 100,000BTT)
Will theappllotd m future buildingoccupan ort.r1undleh.niou.
material see defined bythe Cupertlw MuMdpal Wd Chapter9.t; andthe
Date ReEei [#
HEATINU
G NIT (OVER 100,000 BM
TO TAL.
Ele,It YSafety Cod,, SSectlm 75537 W7
❑mM o
Rtum
VENTILATION FAN 61NICLE RESID)
ISSUANCE DATE
Wel the .pp[aot building oeupant use equipment or cl v
whkh emit hen rd -us ab antambaMa as deflated by the Bay Arta Nr
BOILER -COMP OTE' OR 100,000 SM
Quality M rtagamord Dbtrict7
Yve ❑ No
have mad the havrdous materiab requlmmenb under Chapter 6.95 of
the C.hfamb Fleakh & Safety Code, Senora 75505, 75533 and 75531. I
understand that lithe building don not mrently have a terant, that It b my
t
Pf IIM '
-PAID
BOILERmMP(OVER 100,1100 BTU)
NEW RESIDENTIAL M.ECR SQFT
responsibility to notify the oavpant of the mquim.t.whkb rust be met
prior to unu,,. a. Cedifiate ofOavpany.
1 O
DECtL 991
ISSUED BY'
a
Owner or,uthorind agent Late
IDTAL
OFFICE COPY