23280 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
fluming Project Identl(latlm IPFRMITNO. -/Jit '//�/�
Building Address: -
- - 1 V O &e
/26r Car-
23280
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CIN OF CUPERTINO BUILDING DIVISION �-f
can ns,/.Name Lic.No: APPLICATION I PERMIT !i
60 ,3TV BU1LDiNGELBC CAL PLUMBINC-MECHAMCAL CATEGORY CONTROL,# -
ArchttM/Englrcer. Llc N.
ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addroad5xLim mom Sr1)j9bjPERMIT15S7JANCE ❑ ❑ ❑
LICENSED CO.NMACTOR'S DECLARATION
Ihe¢byaf(Irmthat l am llcenaeduMer Provisluendchpteri?(.c, APPUANCESRESVJFML BDESC INIA
ingwith Section7000)ofDMaon3ofthe Budnesand Profna Cade,andmy
limnse is In full force and effect. PANELS
LI¢nse Class Lice W E
Data Cu
omctor
NO pARCHITECTS DECLARATION - -I AMUS
Z I urdestand mypbv shall be ureci As public record• OVER1000AMPS SQ#W." AR $/SQ.IT.
Licensed Pmfesbnsl SIGNSELDCTRICAL _ �` L)) rNN
OWNER-BUILDER DECLARATION , SPECIAL CIRCUIT/MISC KU T
7
E. 6 1 hraby a/Omnth.t I am exempt from Contractor's Law(a the
>9 q bllowing reason.(Section 70315,Bushes AM Profesbns Code:Any city or .
($GF-qqqq�y IFIAP.MEI'Qt OR POLE MST.
K5ai3 muntywhlrh requb¢•pertNtromvrequirsthemplicantemol6h,ormpir - - -0;-/M2-17
Y,�7 any aainuapMtent tssurrgak,vmsed pursuant
to
rr•uccosiof to f�N,pR DEVICES
C 0.� Ole•dgned statement titre M 6llanxd punwnt to the prvvfebv of the
2NContractor's Lkew Law(Chapter 9(mmenencing with Section 7000)of Dh4 SWIMMING POOL ELECTRIC
4El0< ebn3o(the Busim=dPrd mCode)orthahe6e niptthemfmmard VALUATION
the Inst for the alleged exemption. Any Wdatbn of Section 70315 by•ny
Q
Applicant for a permit subjects the.ppllcant to.dsil penalty of not more than OUTLETSSWITCHES-FDMJRES
�C fivndrcd dollars,($5M.I,as.,of the property,or my employ.with wages u their sole NEW RESIDENTIAL ELET:IR SQFf. STORIES TYPECVNSIRUCIION
compevrtion,willdothew¢kandthearunure6mtlmerdN or offered for
5 r�0 sale(Sec 7014,Basions and Profesbro Code:The Contranole Llarne law
P�$g
whod ceapupclywtohanomwrclr(mthmmghhw6wbnenipIcim,rpwidthdertmant,aunchd -
OCCGROU' RES,UNITS
Improvemrcuntenddoro/feredfms6.
Khmwemr,thebuildingor TOTAL
Impmvemcnt b sold within oneyearo/ttmplcibn,the avrier-builder will have
tkalluncien of proving that le aid not build or lmprmm for purpose of ale.). QTY, PLUMBING PERMIT FEE
U I,as r of the property,am excluaWely comr ing with o-- flOOD7DNE AINowne
conix.to mntrurt the Project(See 7014,Buslra,as and Professions Code PFRMU NUANCE
The Comnmrl License Law dm not apply to an owner of property who
bullEa or Improves thereon,and who mMram for such plojecta with a ALTER-DRAIN k VENC-WATER(EA)
cyalfactur()llanaed pursuant to the Contractor'.Lianas Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sm B k P C for this reason
DRAINS FIOOP,ROOF,AREA,GOND. SANRARY Y_ N_
Owner EC1
WORKMAN COMPENSATION DECLARATION I RECEIPT AFO(HIRESPR TRAP SCIIOOLTAX Y_ N_
❑I hereby roke a that I has,•• Insu ate of invent ci copy
(Sa RECEIPT
certificate,Lalof Workeni Compensalmulvuan¢as,¢rtVled copytheuro((Sec. GAS EA.SISTEM-1 ING4 OUTLETS PARK FEZ Y N
Policy
0 G
a GAS.EA.SYST C)VER 4(EA) DING DI
yfflcd BUILDING DIVISION FEES
copy 6 henebyturri ly GREASE/INDUSTRL WASTE INITRCET"COR PLANCHECK FEE
e_"copy b fikd with tk city Inspection dfdJan. _
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATIONINSURANCE
SEIVFR-SANCCARYSWRM EA_30aFC Date Recei tit
(TNsaectbn need net be connplead lithe SpermitURA 6(more hundmf dollars
(S100)almJ WATER FIEArFR w/vEN'rIETECTR ENERGY FEE Y N
1¢rdfy that In the per(omuna of the work forwhich this permit b lowed,
I•hall sat empty any person In any manner so as to become subject to the WATER SYSTEM/TREATING PAID
w¢ke�eompenatbnlAwsoraluaw.Date
O = NOTICEt NEW RESIDENTIAL PLMB. SQFC. Date Recei tic
Z 0 NOTICE TO APPLICANT:U,after rvking lits Certlflate of Fxemptbn,yw
should become subject to the WdrFeri Compensation provisions of the Labor TOTAL:
CC fn Code,you mua forthwith comply with such provisions or this permit shall be BUILDING
j deemed rooked. _
CONSTRUCTION LENDING AGENCY SEISMIC FE
FEE
LU
CL I henebyatRmnthatthere6aconstvction lording agency for the perform ELECTRIC FEE -
Z sruedthe workforwhlch this permdb 6wod stat.309'7,CIv.CJ Tor
U O Lorderb Name PLUMBING FEE
ly F Lender.Address QrY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW IanUythrtlluve aadthbappllatbnard pate thrttheabove lnfornwian
1 iscomed.lagreetocomplywlthaucityard countyoNlnanmandaatelaws PERMIT ISSUANCE FEES PAID:
} N s,1.Vngtobulklingmvtvnlon,aMd mbyauthorbeapresntativeso/thio
F Z city to enter upon the above-mentbrcd property for io
bupectn purpiars. ALTER OR AUDIO MECH. Date Reee
V Z (We)agar to save,iMen fy.n d keep h.,H.the City o/CupeAb l t#
agaWtlhblOtic.,jrd men masand apensna ldu mayN any wvyacvue AURHANDLINGUNI7'(TOT0,130OCF1,I) SUBTOTAL
.g.lvta ofthe of this permit. AIR HANDING UNIT(OVER IO,"CFT) CONSTRUCTION TAX
tJ cof AppVant/Cmtnctm Date EXI lAUSC HOOD(W/DLC'U CONSTRUCTION TAX PAID:
FEAT RDOUS MATERIALS DISCLOSURE
Will the applicant a Wtua buildingonupant more or handle harardous HEATING UNIT(10100,000 BTU) Date RCCCI tit
m.tertai a•deOrxd by the Cupertiw Municipal Cade,Chapter 9.1 Z and the
I Icallh and Safety Code Section 2S532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes
Will the•ppliok m "m Wiling omrpant use equipment or device. VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit havrdmo air mnturri as de0red by tM Bay Area AJ,
+� Quantyy
Mans
gemeru Dletrtnt BOILER MPOFNOR 100,0(10 BTlI) P A I D
4Yes No
1x.ere.dthehar�rdauwerialsnequirementsunderChapterG95of BOIIERNNP(OVER IN,000BTU)tho FEB.rd.uamh at Ift h k Safetyhinn Gods,of cu ru 255Acurrently
lit Zc.tcand,that i i E - 7 192
nespontardthat Vththe building not the
meats which
that it mat NEW RESIDENTIAL MECfi. SQFI'.
ropovlbWty to notify the ocmpaid xx the reqularrcms which mum be mot
prior tofaance ofaCertlRate otOavpamy. CITY OF CUFtlyl iryV
Owner¢authorfad agent Date ISSUEDB ---L
TOTAL:
OFFICE COPY