23066APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification -
Building Addmas:
:23500CRlsro ,��y1v(_ *'305-F-
PIERAETNO.
2306
re aces: n one:
G.t'trwm K(p��04f3URLc
, CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUMD1NGELECnUCAL.PLUMBINO-MFLk1AMCAL
c actor. Name: Lk. No:
pAPItA6L CoN512U�T1�1 SOLI -I I'
CALORY
CONTROL M
AvnrchlteaY/Enyneer._ Lk. Na
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Addresa:
❑
PERMITISSUANCE ��
LICENSED CONTRACTOR'S DECLARATION
I hereby a((Inn that lam licensed under provisions olChapter9(mmmenc
Ingwith5edion7OW)of DiviYon3ofthe Busimnand ProfessionsCode,and my
license la In (uB and effect. SO("7 / /
LlcenseC�Lk.N l ?71
DateJ2 Contractor /nl4
APPIlANCESRESIDFNfIAL
JOB DESCRIPTION
/I/♦/ �'
PANELS
UP TO2DDAMPS
201-1000 AMPS
ARCHITECPS DECLARATION
Iunderstand my plass.hall be used se publicremtda.
OVERIOWAMP5IF
SQ VARIAN
UE
S/SQ. FT.
SIGNSELECTRICT/
Licensed Professional
a.,�
1��,�1
SPFO]ALCRiCUIT/MISCCOM
OWNEReBUILDER DECLARATION
a Contactola License Law for the
1 herewing reason.
ason. that(Sed I am exempt froBusiness
county hick re .(SMa n 7031.5, permit tocom uct and Prn(esskns Code: Mycttyir
county requires permit Improve,t h,ormit
PW T E
3 Z3 Z
-
TEMP. ME ITR OR POLE INST.
structure th for..
e,lxur requlter,iresto
any a sucturttatemeits hat he Is slwrequ Pursuant to the forsucom, of to
file a signed statement That M b Licensed pursuant to the provisions of the
LOWER DEVICES `-
SWIMMING POOL ELECTRIC
I71LE15-SWITCFEFSH%TURES ' \
Contractor's License Law (Chapter 9 (mmmenWg with Section 7000) of Divi-
Yon3 of the Bulb essand Prokb
mns Code) orthat he is exempt therefromand
the basis for the alleged exemption. Any violation of Section 7m1.5 by any
applicant for a pemdt subjects the applicant to a civil Penalty of not moretlun
.VALUATION QU
-L) O p' s ,
L
five hundred dollars ($SM.
�1, as owner of the property, or my employees with wages as their sole
NEW RESIDENTIAL ELECTR SQFr.
STORIES
TYPE CONSTRUCTION
compensation, will do the work, and the structure Is not Intended or offered for
sok (See. 7094, Business and Professions Code: The Contractors License law
does not apply to an owner of property who Wilds or improves thereon, and
don such work himself orthmugh his own employees, provided that such
.
OCCGROIIIa
-RM UNITS
Improvements
Improvements are not Intended oroffered for sale. If, however, thebullding or
TOT
Improvement lssold withinomyearofcompldioMtheowner-buMerwlll have
tti,ilurdeno(provingthathe didnot build orimprove for purposeofsale.).
LJ 1 as owner of the property, am exclusively contracting with licensed
contractors to mwtrud the project (See. 7054 Business and Professions Code:
QTY, PLUMBING PERMIT FEE
'
FLOOD TONE
APN
PERMR ISSTIANCE �s
The Contmdor's License Law does not apply to an owner of Property who
Wilds
Wilds or Improves thereon, and who contracts for such pgoj,bs with •
-MIT-dor(s)licensed pursuant to the Contractor's License Law.
I am exempt under Sea B A P C for this reason
ALTER -DRAIN A VENT (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
DRAINS FLOOR ROOF, AREA, CONI.
SANITARY Y_ N_
RDCEIPT N"
Owner Date
WORIOHANCOMPENSATIONDECLARATION
hereby affirm that I have a certl0ate of consent to self- Insure, ora
certificate ofWorken' Compensation Insurance or a certified copy thereof IS..
M00, IAb C.)
pollryp 02 700 5-1/
AIX7.URES PER TRAP
SCHOOLTAX Y_ N_
BBC=s
GAS EA. SYSTEM -1 INC4 OUTLETS
PARK FEE Y N
RECEByrN
cc��m����yy955aa�aa nv T
cc
CAS FA.SYSIFM-OVER4(EA)
BUILDING DIVISION FEES
copy ls herebyfurnished.the cid.
Certified copy is filed with IM1e tlry inspection division.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECKFEE ,
�—
GRFASETRAP
CERTIFICATE OF EXEMPT ION FROM WORK ERR'
PAID '
COMPENSATION INSURANCE
(Thlssectlon need ma be completed If the permit Isfor one hundred dollars
Date Reoel [M
SE}ypR.SAMTARY-STORM EA 200FC
WATER HEATER W/VENT/FLECTR
ENERGY FEE Y_ N_
PAID -
($100) Icernles)
I certify that N the performanceany
m work for which this permit is leo the
1 shall not employ any person In any manner at u to become subject to the
Workers'Compeneatlon Lawn of California. Date
WATER SYSTEM/TREATING
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Workers' Compensation provisions of the Labor
Code, you =at forthwith comply with such provisions or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
NEW RESIDENTIAL I'LMB. QFC.
Date Reeei tp
TOTAL:
BUILDING FEE
-
SEISMIC FEE
Iherebya((irm that there is a construction lending agenry(orthe perform-
once of the work for which this permit Is Issued (Sec. 3097, Civ. Q
Iaruler's Name
L.endera Addreas
ImAifythatlhavereadthL appliatbnandgatethattheaboveln(ornutim
iscormd. l agree to comply with all city and county ordinance and Yate lases
TO �+
r
ELECTRIC FEE 1 4
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating to building mrotructlon, and herebyerty ori n rcpresenpurpo of this
city (Wenter property inspection purposes.
eeupon to see,Indhe emnify in
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
against which may In anywayaceme
Date Recci[M
ALTER OR ADD TO MECH.
AIR HANDLING UNIT CTO 10,000 CFM)
SUBTOTAL:
ici City indgmenb, ceoftdexpenses
agaryyts�Id City N con ' of the gran g of this permit
�, L- oG2a� �
AIR HANDLING UNIT (OVER 10,000 CFM)
-
CONS'T'RUCTION TAX
Signature of Bcant/Contr ctor Dare
EXHAUST HOOD(W/DICT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BT1p
Will the applla Mnt or future building occupant store or handle hazardous
material as defid by the Cupertino Municipal Cade, Chapter 9.12, and the
He It Yend Safety Code Section M24
Yes �1+�-�l No
Date Reeef IN
HEATING UNIT(OVER 100,000 BTU)
TO A
VENTILATION FAN (SINGLE RESID)
ISSUUANppCEDATE
4'Y 1 N
��
Will the appilant or fulum building occupant use equipment or devices
whality Mancrut agement District?cardousair arab as defined by the Bay Area AirQ11
Yes MN,,
havemad the hazardous materials requirement, under Chapter6.95 of
BOILER-COMPOHPOR 100,000 BTU)
BOILER -COMP (OVER 100,000 BTU)
the California Health A Safety Code, Sections 25505,25533 and 25534. 1
understand that if the building does not currently have a tenant, that it is my
responsibility to notify the ..pact of the requirements which at be mss
�-� yrs
91
NEW RESIDENTIAL MECA. SQ.FT
—
prior to Essuanco of a Certificate of Occupancy.
yr
VVrt
�I
Owner or authorized agent DaoISSUEDB��Y�`r_l1Ye
TOTAL:
OFFICE COPY