23279 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulldln Pmet identification T PER,WTNO.
Building Address: - 23279 3/"17
G?�f L.(Y)✓IV Lim CITY OF CUPERTINO-BUILDING DIVISION
ca to eN,m: APPLICATION I PERMIT
3I1fLLNNGELECTWL
CAPLUMBINGMELIUMCAL CATEGORY CONTROL,1
rchltect/Engineer Ll No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add reu 2 pERAgTISSUANCE O El
❑
LICEND CON'TRACTOR'S DECLARATION, 'I
I hertby.(llnn SEthetl.m lkenxdunderprwleloru o(CFupbr9(annmrn AP[rLIANCESRE9DENTfAL JOB DFSC 1TIO N
Ingwe IsI.full force of Dlvblon3 olthe Budwsand Pmfntlau Cade,and -
IkevebIns fora and e.0 PANELS
LicenDat,_ Class Lb e —
Date Carrtnctor UP TO 200 A�4T`S
ARCHHECTS DECLARATION 'UMC
µOIy ZO I understand mypbru.heBbeused a a pubkmourda OVERII700AMP5 R $/SQ.FT.
k y Fj' Licensed Professiaml SIGNS ELECTRICAL E R
G< ONTJER-BUILDER DECLAMTION SPEGIALCIRCUIT/MLSC / 2
IhenhyaffirmtFtl.meaemptfrmntheContr.toesLianaLwfmthe ATE
pp following reason.Section 7(015,Buslr�and Pro&nbm Code.Any efty or
r 2 TEMP.METER OR POLE INST. `
� muntywhk requU spec tommtrucLalter,lmprw de=lWh,orrepalr
anystaturt prbrto lb Lssuancx,.borequinvthe.ppllmtlmwchpermXto LOWER DEVICES
O file•signed statement that he b Ikmsed punumt to the provisions of the
zu� Contractor:License Law(ChapterI(commencing with Rendon 70M of Dlvl- 514IIdWNG POOL ELECTRIC VALUATION
COs cion 3 ofthe Budnns and Pnoferbm Code)or that he b ecempttherefromaM
the basisfor the alleged exemption. My vldatbn of Setbn 70715 by any
< ppH.tfor.permed subjects the applicant to a civil pemBy of not more than OUTLETS.9VITCH6FD(TURES
five hundred dollars(SM.
❑1,.,ewnereftheproperty,ormyempby.n hwages.,their sole NEW RFSIDENTLM.F�79CIR 9Qx7. STOWES 'TYPE OONSTRU(7DON
Cmpensallm,wBldothe k,.nd therttla b roWended eed or offend for
5 0 sale(Ser.7014,Bualneo.M Professions Cade:The Cofactors Umme law
s8 don rot apply to.n owner of property who builds or improves thenen,and OCG GROUP RES UNITS
whodoeawchworkhlmaeBmthrwgh hisownemployen,provided Mut such
Improvenew are rat Inirnded oroHered(meale.If,however,the building m TOTAL: ,
ImprvvemeM bedd wtluln orcyearo/cm,pltbry the ovnerkullderwlll have
Upl4urderuf proving that he did net WBdorimpnvefmpurpeseofsale.). QTY. PLUMBING PERMIT FEE
I,as owner of the property,am exclusively cont—,with Ibemed FIAOD ZONE APN
contractors to cunmurt the pro),ct(See 7D14,Business.nd Professbm Code: PERMIT ISSUANCE
The Contractor.Lice.Law don not apply to so owner d property who
Wads or improv thereon, and who mnncb for such p�ojeN with a ALTER-DRAW 4 VENT-WATER(EA)
ALV+due(.)llaesed parun.nt to the cono-aeor.Lice.Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
L�I am exempt under Sec B k P C for this mason
DRAINS FLOOR ROOF,AREA,ODND. SANITARY Y_ N_
Owner Date RECEB'T 0
WORKMAN COMPENSATION DECLARATION FD(TURES PER TRAP SCI100L TAX Y_ N_
❑1 hereby oM m that I have a I certificate of convent to seB-ir e n f a. R��(s
anlflab of Worken'CompemaManlmunna a.atBled oopythereo((Sec. GAS FA.SYSTEM-1 INC-40IfILE'I5 �� ' PARKFE Y N
3800, V CJ
Coma GAS EA.SYSTEM-OVER 4(EA7 DING DI
y BUILDING DIVISION ISION ETES
CetlRed mpyb hereby famished. GREASE/INDUS'TRL WASTE QJ7ERCQ'70R PLANCHECKFEE
Certified copy I.filed with the city Inspection division.
CERTIDCATE OF EXEMPTION FROM WORKERS GREASETRAP PAID
COMPENSATION INSURANCE SElVFR-SANITARY-STORM EA IDOFT Date Recei HI
(Tula section need no be emopleted Buhr permit b fororc hundred dollars
(510()mien') ENERGY FEE Y N
I certify that In the performance ofthewok for which tub permit b'suER
ed, WATI� EN
ATFRW/VT/ELECTR -
I,hall not employ any person In any Hunner o n to become subject to the WATER SYSTEM/TREATING '
Wmken'Compem.McnUwse(Californb. Date PAID
-
zZ Applicant NEW RF9DFNIIAI.PIl ig. SQ.FT. Date Recei tot
Z 0 N UCE'TOAIa[aLICANT:Ifaaerm ngthb Certlfioteof Fxmprbn,you ,
should become subirct to the Warkm'Comperu.tbn provisions of the Labor TOTAL
Q y Cade,you must fothwNh comply with such provisbm or this permit shall be
deemed revoked. BUILDING FEE
W ' CONSTRUCTION LENDING AGENCYSEISMIC F�E
a Ihereby.fMnthat thercba mmtrocdon kid Ng agency for the perform- ELECTRIC FEE
Zanaoftheworkforwhlchthbpemdthbsued(See3097,Civ.C.)
Q2 Lender's NaT
me PLUMBING FEE
U. H Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Iadlfy the I have mad thbappatbn and statethat the above Fdomrcdon
Lsrormi.Iagm to cwnplywW aB tltyand county ordWnas and state laws PERMIT ISSUANCE FEES PAID:
.} 0.N relating to building comuvtian,and hcm1hy.utharb represenbn tWof this
Z city to enter upon the abov mentbmd proprtADI
)TO fee Inspection purposes. ALTER OR ADTO MEEK
_ (We)agree to save,Indemnify an of keep harmless the City of Cupedbo Date Receipt#
agaWtllabBltfn,}ndgnrNe,tsK.and expenses which may In mywry.cwe AIR HANDLING UNIT(IO 10,0)0 CFM)
SUBTOTAL:
ger B�y(N(��A ens of Mie .(rids pemnlL AIR HANDLING UND'(OVER 10,000 CFM) CONSTRUCTION TAX
uof J 1 L/M Ll+L CONSTRUCTION TAX PAID:
SI tar's of Applicant/Contractor Date FxFIAVST HOOD(W/DI1CD
HA 2!A RDOUS MATERIALS DISCLOSURE
Will the apred by One
t iding occupant mom orhandkhavrdthe (:EATING UNIT CTO 100,000 BT" Date Revel IM
' mrterbludrlined bythe Cupetlro Municipal Code,Chaptcr 937,and the
health and Safety Cede Section 75S32(a)7 HEATING UNIT(OVER 100,000 BTU!) TOTA
❑ Yee No _
WDI theapplioan,m ture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANIZE QA�E
which emin
t lurdous air eontaMmats as defined by the Bay Area Ab
QuAftyy Management Diana? BORER-NMP OIR'OR 100,000 BTU) FEB
-�'
Y. No 4havereadthe], ,mate requlnmenmunderCuper6.95o( O QbCOMPOVDIW,000B D 1ni
the Cal fern's Heahh k Safety Code,Settom 75505,E533 and 75574.I s7 S'
undeata nd that ifthe WBding doen nor currently have atenanL tint it b my NEW RESIDENTIAL MEC3i. SQ1.7
rmpom ility to notify the occupant of the requirements which must be met V C
priortoL uaereofaCerMOcateofoccvpanry.
Owner or authorised agent Date ISSUED BY:
TOTAL: ji
OFFICE COPY