23950 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Idemlllotian PFRMITNO.
B"llding Address:s 23950
s E s
came: npe: � A
W f— Ler- /Ls'j 886 CITY OF CUPERTINO-BUILDING DIVISION
. Contr or'eNa T LI Nn: APPLICATION / PERMIT
4 `��;�/ BUILDING-ELECTRICAL PLUMBING- CATEGORY CONTROL
Architect/Engineer. LIc.No: MECHAMCAL
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: +�
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION PERMITISSUANCE
I herecetion70thafDNIsin3of under prossand of Chapier9de,and y APPLIANCFSRESIDENIIAL JOB DESCRIPTION
ingweh in
effeon3o(the Buslussand ProfesslonsCode,and my f PL ��
Breese isle fuBjufce ped erratrrAPANELS
License C6m Li33 7�/
Date Caamctor UP TO 2DO ANTSN�!
ARCHITECTS DECLARATION 201-1000 AMPS
1 j
WX I understand my plam shall he used as public records. OVERIOOO AMPS iP�gF® $/$Q,FE
CC SPECIA LECTRICT/
U Licensed Professional
<� OWNEReBUILDERDECLARATION SPFOIALCIRCUIT/MLSC A-
7H � owing of@mthalam31.5,Bxempt iro es the
sad Pretctorb Llcensa Law city the
or i
followingrecon.iresap permit
re Business andr,impr improve,
Code:Any city it
O�F..� TEMP.MEl'ER OR POLE INS!.
PEI countywhichctime requiters permitro reconstruct,alter, applicant for
rcpatr
.a anystrocture pdorm lm 6manee,a6o requlreathe appllant for such permit to POWER DEVICES
c. file a signed statement that he is licensed pursuant to the provisions of the
3µO Contractor's License law(Chapter 9(ce.,wing with Section 7000)of Dlvl- SWIMMING POOL ELECTRIC
n3afthe Business and ProfeselonsCode)orthat he is exem therefmmand V O
Q 5 tiohe basis for the alleged exemption. Any violation of Section 7MI.5 by any OUTLETS-SWITCHES-FIXTURES
applicant for a permit subjects the applicant to a civil penalty a not more than
eg five hundred dollars($W. NEW RESIDENTIAL ELECTR SQ.FT.
0 J
F-1 1,as owner of the property,or my employees with wages as their sole STORIES TYPECONSTRUCTION
< compensation,will do the work and the structure 6 not intended or offered for
p
sale(Sec.70K Business and Prefeadom Code:The Contractors License Lw
does not apply to an owner of pmper(y who builds or improve thereon.and OCC.CROUP RES.UNITS
0. who dexasuch work himself or through hisown employees,provided that such
improvements are not intended or offered for sale.If,however,the building or TOTAL:
improvement ii sold within one yearofcompletion,the owner-builder will have
the rd en of proving that he did net leu lld or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
Lj L as owner of the property,am exclusively contracting withn—
Contractor's
7064,Business and Professions Code: PERMIT ISSUANCE
The Contractors License Law does nal apply to an owner of property who
Wilds or improve thereon, and who contracts for such pmjem with a91
ALTER-DRAM&VENT-WATER(EAI
<,5.cmr(.)licensed pursuant to the Contractor's License Law. BACK I7AW PROTECT.DEVICE FEE SUMMARY
L�I am exempt under Sec. B&P C for this reason
OUTSIDE F
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEIPT.N
WORKMAN COMPENSATION DECLARATION FIXTURES-PER TRAP SCHOOL TAX Y_ N_
❑I hereby affirm that I have a certificate of consent to sal(-Inmrre,or a RECEIPT N
certificate of Workers Compensation Insurance cr a certified copythereof(Sec. GAS EA.SYSTEM-1 PARK FFE Y
38 N_
00,lab C.)
Polm any GAEA.SYSTEM-OVER 4(EA) BUILDING DI
DIVISION FEES
Certified copy 6 hereby furnished.
Certifiedmpy6filedwlthih dtylnspMiondivl.ion. GREASE/INDUSIRLWASMINTFRCEPTOR PLANCHECK FEE
CERTIFICATE OFEXEMITION FROM WORKERS' GREASE TRAP PAID
se
COMPENSATIONINSURANCESEWER-SANTfARYSTORM EA 20OFT Date Recei t#
(Thisctlon need nal W compicted if thhe permit 6!stone hundred dollars
($100)or lay.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certifythat In the performance of the work forwhlch this permit is Issued, —
I shall not employ any person In any manner so m to become subject to the WATER SYSTEM/TREATING
WmkrWCompensation Lawsm Califomla.Dae PAID
O Z NOTIAppliCE
NEW RESIDENTIAL PLMB. SQFF. Date Recei t#
Z O NOTICE co APPLICANT:to
after Workers'
th6Certnlateof Exemption,you
H N shouldou=ame, Fade tothe ply with
Campematlunprovhis perlone it the s Labbe TOTAL:
Code,you must forthwith comply with such proWlom orth6 permit shall les
W > deemed revoked. BUILDING FEE
CL f] CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z Iherebyaffirmthat there 6a construction lendmgagenry forthe perform I !- ELECTRIC FEE
ance of the work for which this permit 6 lowed(Sec.3097,Civ.C.)
u O Lenders Name PLUMBING FEE
LL F ]ender§Address QTY. MECHANICAL PERMITFEE MECHANICAL FEE
O W Icedtfythat l have mad this appliationand statethat theabove lnfainatlon
0. 6correct.I agmeto comply with all city and county ordinances and scale laws PERMIT ISSUANCE FEES PAID:
>. W relating to building construction,and hereby authorize representatives ofthis
H Z city to enter upon the above-mentioned property for inspection purposes. ALTLR OR ADD TO MECH. Date Recel t#
V
against habbilitie,save,Indemnify
avis and eTxpand epes which
in ity
Cupertino acenue F
ga judgments, anting which nnyln anyway acwe ALR HANDLING UMT(To 10,000 CFM) SUBTOTAL:
against said City In consaqueslR of the Ranting of this penult.
AIR HANDLING UNIT(OVER 10,0)0CM) CONSTRUCTION TAX
Sigratum of Applicant/Comonnor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZA BOGUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or its ad le hazardom HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
Healthand SafetyCode SM1on25532(a)r HEATING UNIT(OVER 100,000 BTU) TOTS ^
nyes No
Will the applicant Nauru building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the flay Area Air rre�nn
Quality Management Distinct? BOILER-COMP(3HP OR 100,0(10 BTU) F
4 Yes No
haveread the bozo our materials requlscments underChapter 6.95 of BOILER-COMP(OVER IOO,OW BTU)
theersta dt Health& tatty Code,Sections 25505,W25533 aternd25534.] JUS. _ 9 '1997
understand that l(the chiding snot mras haveatcnanl,that it6my NEW RESIDENTIAL MECH. �.Ff. saF.
responsi Ill ant oftheregWrementswhichmustbemet
prior to m e 1 eo racy.
day 'f 1l Y ur Cu =�n}nQl+v �
n ror auth sad TOTAL:
' agent Date I ISSUED BY:��'r'' f1
OFFICE COPY