23208 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro ect Identification PERMITNO.
Building Address: /7�1 0
O Lv G 3
C/0-1 /3i// /ZQm pec CITY OF CUPERTINO-BUILDING DIVISION
Con ctorsName: Lk.No: APPLICATION /PERMIT
L O 7 BUILDING-ELECTRICALPLUMBINGMECH LAICAL CATEGORY CONTROL N
A ited/Enginmr. Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add.2Z Q PERMITISSUANCE �� KIS ❑
LICENSED CONTRACTOR'S DECLARAT tf
I hereby affirm that l am licensed under provisions ofC aPtcrq(cxmmxme MPLIANCESRFSTDENTIAL JOB DESCRIPTION
ingwlth Sedton7OW)of Dlvision3ofthe Buslnenand ProfesslonsCode,and my '
Iimnae Is in full form and effect. PANELS
Llmnse Class LieN
Date Contractor —UP TO 2DDAMPS
,-
ARCHITECPSDECLARATION 201-IOWAMPS
Q 2. lunderetaMmyplznsahaBbeusedepubbcrcrords. OVER 1000 AMPS SQ.FT.FLOORAREA VSQ.FT.
E o Limewd Profeubnal - SGNSELECTRICAL
<< OWNER-BUILDER DECLARATION
1-n]3 SPECIAL CIRCUIT/MISC
owingra(Brmthatlam exemp(romthe Contractor's License Law(ortha
following reawn.(Benton 7B715,Buelnesv and Professions Cade:My dry it
O i.. TEMP.METER OR POLE INST.
F� coystm= pre rima Le anct aworequi thlmphuntfreve,derroWh, er ttr
q any structurep Cement Lhat he is aism ed put .t to the farwions of it a ppyyEg DEVICES
file a signed statement that he is Bcenved pursuant to the provisions of the
SOwl Coronado,'.License Law(Chapter 9(---do&with Section 7000)of Dlvl- SWIMMING POOL ELECTRIC VALUATION
OS aion3ofthe Buslnemand Professbv Cade)orttat heisexempttherefromand
a the basis for the alleged exemption. Any violation of Section 7015 by any OUTLETSSWITCHESFIXTURES goo
applicant for a permit subjects the applicant to a civil penalty of not more than _
five hundred dol Ian(¢,00).
❑I,a owner of of property,or my employee with wages r their vole
NEW RESIDENTIAL ELFLTR SQFP. STORIES TYPE CONSTRUCTION
7 Ci compensalien,will Business andhe k fteadmnd the t Code:Th moue oe or offeredLaw
D ole(sec aptly Business and Professions Code:The or Improves License Law
$ don not apply m an owner of property who builds or Improves thereory and OCC.CROUP RES.UNITS
who due
ssu mama himself e hrough hisown gor
Improvementsarenot Intended oro(fered(prole.IL ranee q flder ilI have T
Improvement iswld wlohinoneyearn(completlorytheowner-bu0derwill have
it Orden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
u I,as owner of the property,am awh aimly contracting with Ilnnsed pp�(MfT ISSUANCE
contractors to construct the project(Sec.7004,Business and Professions Code:
The Contractors License Law don not apply to an owner M property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improve p
thereon, and who contrasty fur such mojeats with a FEE SUMMARY
cga(panor(s)limned pursuant to the Contractor's Ltmnse Law.. BACK FLOW PROTECT.DEVICE
Lj I am exempt under Sec. B k P C for this mason
DRAINS FLOOR ROOF,AREA, SA ARY Y N
Owner Date RECEIPTN
WORKMAN COMPENSATION DECLARATION FIXTURES PER•TRAP SCH TAX Y N
❑I hereby dftrm that I have o mrturanc of a want m upytheurc,ora RECEIPT'N
mrtiftutee(Workers'Compensadonlnsuranmmacertified ropy thereof(Sec. GAS F.A.SY PARK FEE Y N
3800.Lab CJ
Policy N f RECEIPT M
Com n4, , GAS PA.S 4 �j 1 BUILDING DIVISION FEES
2Ce Tfiedcopyls heneby(umlahed. CREASE/WD sIEI R PLANCHECK FEE / "7l / O
ertl(led copybfiled withthe ntylrupenlon divi l [ b
CERTIFTCATEOF EXEMPTION FROM WORKERS' GREASE7RAP P PAID
COMPENSATION INSURANCE SEWER.SANITARY.SPORM EA 20017T Date
f(forless.) need not be completed tithe permit islemons hundred dollen
(f100)oify that
WATER HEATER W/VENT/ELECTR ENERGYFEE Y
I certify that in the performance of the work for which this permit is issued,
I shall not employ an parous In any manna} Ar� to act to the WATER SYSTEM/.I.RFATI .
Workerc'Com/pg /qo/(/{!/jilt$ it ate PAID
O Z Applicant � NEW RESIDENTIAL ELMS. SQ.FT. Date Reoel t#
- Z Q NOTICE rO MSP ICANThiker onafleingI CertKam of Exemption,you
should become subject to the Worker'Compensation provisions of the Labor TOTAL:
MCods,you=at fork twits comply with such provisions or thin permit shall be BUILDING FEE
LU _ doomed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
[1 I sereby affirm that there be a construction lending agency lorthe perform- ELECTRIC FEE
D O ance of the workfer which this permit is Issued(Sec 3097,Civ.Q TOTAL:
Lender's Name - PLUMBING FEE
LL F Lender'sAddmst QTY. MECHANICAL PERMIT FEE
O W re
I certilytsat l have ad thisapplicallonand statethatthe above Information - -- MECHANICAL FEE
a Is correct.I agree to comply with all city and county ordinances and state laws 1 PERMIT ISSUANCE FEES PAID:
>. relating to building construction,and hereby authmilbe repreaentativesa(this
N city to enter upon the above-mentioned property for lmpenionpurposea. ALTERORADDTOMECH.
2 Date Receipt#
(We)agree to save,indemnity and keep harmless the City y ayPon
acelm
agaWt Itle,jadgntenb co&send expense which muyN any way acoue AIR 7MANDWNG UNIT(TO 10,000 CFM) SUBTOTAL:
t d city In ce of the granting of this permit.
_ AIR IiANDWNC UNIT(OVER 10,030 CFM) CONSTRUCTION TAX
tureo Ap jj
earl Contractor Drs EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfumm building occupant store or to ed to henrdous HEATING UNIT(TO 100,000 BTU) Date RCCCI
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
Health and Safety Code,SegiidAM532(a)7 HEATING UNIT(OVER 100,000 BTU TO
❑Ye- [3-N-Tu
Will the epplimnt or lure building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
QZ!allty Management DIsW BOILER-COMP OHPOR 100,000 BTU
4Y, o
ave rea
hd the hempus materials requlremeno,under Chapter6.95 of BOILEILCOMP(OVER 100,000 BTU) p{3 p
the California Health k Safety Code,Sedlons 25505,75533 and 25534.1 a'R B
understand that building due.not currently have a tenant,that it is my NEWRESDENTIALMECH. SQ.F .. ®
m Ify the occvpyV therequi..ete which most be met C�
Est oof a Certificate I __Fancy. v�aV FN4 7(�^ l 4,
cO CITY
a7a7�
�o a��utF rind agent Date ISSUEDBY:mss/
TO
OFFICE COPY