23199 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL-POINT PEN ONLY
Building Protect Identification ., PERMATNO.
Building Add mss: 231.V^
9
10500 N. BwD, . 9 of
one: I p
_Aepup cxqA CITY OFCUPERTINO-BUILDING DIVISION
Cortyr'sName: Lie.N.: APPLICATION I PERMIT
• �a BUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL p
Ar itect/Englmee Lk.No:
6�ra�
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: B�SN PERMATISSUANCE ,r OO
LICENSED CONTRACTOR'S DECLARATION X '
I hereby affirm that l am licensed under provisions of Chapter9(cormeno APPLIANCES-RESIDENTIAL JOB DESCRIPTIONIngwithSMion7000)ofDlvlsIm3 ofthe Busimeand ProfesalonsCode,and m
license I.in full to.and died. PANELS
License Class Lt.N
Date Contractor ylUPTO200AMPSM
ARCHITECTS DECLARATION 2014000 AMPS
µ❑Vi O Iudentandmypbmshagbeusdmpub0c.cun s. OVER1000AMPS SQ.FT.FLOOR AREA S/SQ.Fr.
SlotCtk�, Licensed Professimal SIGNS ELECTRICAL I ep 1
I0 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC L E D IN
7F 7, owing reason.
hction7 IS,Buempt roessa Contractor's License law fort he a.�
oo following reason. iSection 70315, ommuci ed Profeemm, Code:My dry it (� K
cauntywhich requUesapenNttoaorotvd,dter,Mprove,demoBsh,orrepalr TEMP.METER ORIOLE(NST. r-
anystruchrepriortoits Issuance,also requireatheapplicimt forsuch permit to POWER DEVICES X799
g� `V77
E5 file.signed statement that he I.licensed pursuant to the provtiom of the
pWd 3 Contractor's License Law(Chapter 9(mmmencing with Section 7000)of DWI. SyyldAgNG POOL ELECTRIC ATE VALUATI
SOS thesto3 of basis for the
aIle a and Professions Any viothat lation f exempt therefrom and
<: the licar for the permit
subjects
exemption. Any violation of nattySectiono 7011.5 by any OUILETSSWTTCHF&FIXTURES r r
O ape hundredaollars subject Neapplkant too civil penalty ofna mom than
live hundred dolts he%W.
pro
I as owner al the property, NEW RESIDENTIAL ELECTS SQ.Fr. STORIES T3TL CONSTRUCTION
�n ❑, p perry,or my employees with wages m there sok
t rom(Sec.7044,will do w ('mea Nes tmtlurctwttractor or License Law
,a p
sale(Sec.apply
to Business fproparty Code:The or Improves
LicenseLaw
rjCS does whodotapply torn owner dthmag hiswho
nemoyeea,povided that
OCC.GROUP RFS.UNITS
Ca•3 whodoessuch mentsw notinte intended
ffemd owns.If,homver,th buildi noruch •�
Improvement amnotIntendedprofferedformb.If,however, deer ill have TOTAL:
Improvement teoW wlthlnomyearo(complNionThe owner-bullderwlll have .
the burden of proving that he did not bund or Improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to corubud the proiret(See.7014,Ruin and Profeadons Code:
The Contractor's License Law dm not apply to an owner d property who ALTER-DRAIN kVENTWATER�A)
Wilds or Improves thereon,and who contracts for such ptojeca - -
twith a FEE SUMMARY
crJp(Iadar )licensed pursuant to the Contractor's License Law. BACK FLOW PRO'1'FL'1'.DEVICE
LI[am exempt under See B 4 P C for this mason
OUTSIDEITFS
DRAINS FLOOR ROOF,AR&A,COND. SANITARY Y N
Owner Date RECEIPT
WORKMANICOMPENSATIONhave
DECLARATION FIXTURES-PER TRAP SCHOOL TAX Y_ N_
❑T hereby affirm that I have o cerourate of Spasm to op theure,ora RECEIxT M
3800'Lateo(Worken'Compensallanlmuranm ore certified copy thereof(Sec. GAS F.A.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3000,lab CJ RECEIPT M
Policy ItRECEIPTEA,SYSTIM-OVER 4(EA)
Comm dray BUILDING DIVISION Fr,ES
_U Certified copy t herebyth thecid. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE ��7 U�
Cenl0d copy t filed with the tlty Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200PT. Date Remi t#
(Thissection need not becomplet d if the permit tfor one hundred dollars
(S100)orlaaa) ENERGYFEE Y_ N
Imdifythatinthepedo.commofthcworkforwhichthispermltla Wved, WATER HEATER W/VENT/dECTR
I.hall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation laws of Calffomia. Date PAID
0 Z Applicant NEW RESIDENTIALPMB. QFT. Dale Remi t#
Z O NOTICE TO APPLICANT.If,after making thisCertBlcate of Examption,you
should become•ubjecVlb the Workers'Compensation provisions of the Labor TOTAL:
N OBde,you must forthwith comply with such provlsiom or this permit shall beRO
W > deemed revoked. U I d O. 01
d CONSTRUCTION LENDING AGENCY SEISMIC FEE �s
Thereby or mthat there I.a construction lending agency for the perform TOTAL: ELECTRIC FEE b. Vp
0 anm o(the work for which this permit t Issued(Se.3097,Civ.C.) -�
lender'.Name PLUMBING FEE
U
<L t= Le.der'.Addms. QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
O L) IcenlfythatI have read thtapplimtion and tlatethattheabove Information
1 incorrect.iagrceto complywlthaUdtyandmuntyordinanonandmmelaw. PERMIT ISSUANCE FEES PAID:
} N relat gobiliti
ng cmetru tory and hereby authorize representativca oftht
H Z city rotheabo -mentlondpmpenyfwimpedbnpurposea. ALTER OR ADD TO MECH. Dale ReCei t#
dsave,In emnity an d keepharmless the City of CupertinoPa 1 siNdg , osis and expenses which may in anywayaccrue AIR HANDLING UJNIT(TO 10,000 CFM) SUBTOTAL: 4 7.97a t m tint granting of thin pertn'. PIR HANDLING UNIT(OVER IO,ODOCFM) CONSTRUCTION TAX
T_hich
er Brent/ o erctl IXHAUS'r Hoop hV/DucT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSU E
the applicant orfuture building occupant store or handle hazardoua HEATING UNIT(FO 100,0DO BTU) Date Reml 1#l as dented bythe Cupertino Municipal Code,Chapter 9.17,and theand SafMyCdp§aation 25532G)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:mNthe applicant u re building occupant use equipment or devices VENTIATION FAN(SINGLE RESID) ISSUANCE DATE 317,07
ost mo,adom air coourrimnt as de0nd by the Bay Area Air
( iality Management Dist d7 BOILER-COMP OHP OR l00,IXp BTU)
4 Yes No
hav eadt az s terialsrequimmenbunderChapter6.95of 86iLrR.COMP(OVEt 100,000 BT[n
the Ca 01 salt Safety ode,Sections 25505,25533 and 25534. 1
unit to t tlft buildin d otmmntlybaveatenant,thallttmy NEW RESIDENTIAL MECH. SQkT
rm 1 li ton the ant of the requirement which must be coat
prio to u roof rnif sof pancy.0'7T.. (zed gmtj Date TOTAL ISSUED BY..
OFFICE COPY