23886 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: 23886
0 0 /n s Wo.
one: A A A
S 5 I C N UILDI DIVISION �y
C°" ae °Name' Lk.No: PLICATION I PERM;
BUILDING-ELECTRICAL-PLUMBIN - FO C ATECORY- CO f]�J��
Architect/Engineer. He.No: W G�
QTY EL PE FE DING PERMIT INFO
Address: ,O, 5 54 /OiU U ® ❑
LICENSED CONTRACTOR'S DECLARATION rA
Ihereby affirm that lam licensed under provisions of Chapterit(comernme. RESID L JOB DESCRB'ITON
Ingwith Sect(on70W)of Divislon3`of,the Busincyasand Profe,k..Cede,and ney `s
Beenreisin ful meand effect, a 117-31--
1
17/Z P 1
Llrense Class Llc.p 7 ✓`p
Date��Z. Contactor
ARCHITECIPSDECLARATION 201-1000AMPS
mz I understand my plans shall beused as public records OVER1000AMP5 SQ.FT.FLOOR AREA $/SQ,FT.
Licensed Professional SIGNS ELECTRICAL
OWNER-BUILD
<Z. ER IECLAIATICle SPECIALCIRCU1T/MISC 7
yip ,7a Ihereby affirm that I am exempt from the Contractor's Ltmnw Law for the
O'L l—� (ollmwing rcasoa(Section 70115,Business and Pro(enlona Code:Any city or TEMP.METER OR POLE INST.
r= n .' c°untywhlchrequU apemdttommtr M-Iter,impmve,demolbh,orrepalr
.� anystrucmre prlorto its isseanco.be requirestheapplicant for such permit to
O file a signed statement that he b lirend pursuant to the provisions of the POWER DEVICES
k Contractors License Law(Chapter 9(commencing with Section 7000)of Divi-
sion 3 of the Business and ProfesslonsCode)orthat he is exempt therefromSWIMMING I00L ELECTRIC and VALUATIOtreoN,
the basis for the alleged exemption. Any violation of Section 7m IS by any OUTLETSSWITCHFSFTES
sip /
° < applicant Iris permitsubjemtheapplicanttoacivilpenaltyofnotmarethan XTIlR !/ L V V
ppll five hundred dollars(5500). NEW RESIDENTUL ELLCTR
p;7 F1 I,as owner of the property,or my employees with wage as their sok SQ STORIES TYPE CONSTRUCTION
C mpematlon,wildothewwkandthertmcwrebnot intended or offered for
5a p sale(Sec.7014,Business and Professions Cade:The Contractors License Law
psi duesnotapply to an owner cfproperty who builds orimpemes thereon,and OCC.GAOUP RFS,IINITR
c. whodon such work h(mseiforthrough his awn employees,provided that such
Improvements are not intended oroffered for sale.I(howeveq thebullding en T
Improvement Issok within ane year ofcomplelion,the owner-bu0der will have
t rden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD TONE MN
4 as owner of the property,am exclusively contracting with licensed PERMITLSSUANCE
contractors;to construct the project(Sec.7066,Business and Professions Code:
The Contactors License Law don nut apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon, and who contracts for such piojects with a
cg�Iltt.Tactor(s)licensed pursuant to the Contractors License Law. BACK FTA FEE SUMMARY
am exempt under Sec. B&P C for this reason T.D
OUTSIDE FEES
Date DRAINS F"A EO SANITARY Y_ N
WORKMAN COMPENSATION DECLreARATION RFOEB'f p
1 hereby affirm that I have a rtificam of consent to self-Insure,or a 1 \ L KI SCIBOOL TAX Y N
\ Ic mo(Workers'Compevation Insurance or a certified copythemof(Sec. RFCEB'T#
rybC.) /O _97 GAS EA.SYSTEM-I INC OOITTLET RK FEE Y N
mp ey7 s GAS EA. RECEBTp
❑Cetthed copy in hereby fumbhed. - BUI EDING DTVI NFEES
E3Certlfed copy b filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE glO�
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Thisseelonnedrmix,compined Bth¢permit Isfurorohundreddollars SEWER-SANITARY-STORM EA.20oFT. Date ece
($100)or less.)
I mmlythat in the performanmofthe work for whim this permit is Issued, WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I shall not employ any person In any manner so as to become subject to the
O Workon'Compen-fie-lawaofCall(omin.Date WATERSYSTEM/TREATING PAID
Applicant
Z p h'OTICETO MPLICANT:IL aOer makingthia Certlfi-mof Exemption,you NEW RESIDENTIAL PLMB. SQFr. to Recei t#
should become Subject to the Workers Compemat ion provbiora of the Labor
(/2
Code,you most forthwith comply with such provbbm or this permit shall be TOTA
W > created revoked. B ILDI
CL
pt CONSTRUCTION LENDING AGENCY S I C FEE
Ihereby affirm that there is a construction lending agency for the perform, EL RIC FE
n O ance ofthe work forwhichthb rmltbb°ued6ec.3097,Civ.C.) TOTAL: s
U _ ;enders Nam �(/r y�e PLUMBING~ E
0 f— cederslyth QTY. MECHANICAL PERMIT FEE MECHANICA FEE
O W Irertifytha,l bave read thin-pplkatlon aednate that theaWve Information
is.renct.l agree to comply withail cityand county ordinances and nate laws PERMIT ISSUANCE PEES PAID:
} N relatingm Wliding ronslmdimn,and hereby authorize representatives ofthb
r Z city to enter upon the above-menRoned property for inspection purposes.veALTFAORADDTOMECH. ��
V — (We)agree to new,Indemnify an d keep harmless the City of Cupertino Date Receipt#
against liabilities,judgmenta,cons and apemen which may In anywayacave AIR HANDLING UNIT(To 10,000 CFM)
aga Wt said City in c; quence of the g/raidi�ng of this permit. TOTAL:
+' f4 (WSJ 10Z/ AIRHANDLING UNIT(OVER l0,000CFM) CONSTRUCTIO TAX
sureo(ApllcaCr/Contraoce Date EXHAUST HOOD(W/DUCT) CONSTRUCTION AX PAID:
]ARDOUR MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HFATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the _ Date eeel t#
-
I lea lth and Safety Code Section 25532(a)? HFATING UNIT(OVER 100,000 BTU) O
I - -❑ Yes ri No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID)
\¢nut hazardous air contaminants as defined by the Bay Area Air ISSUANCE DATE
�Q ",Management District? BOILER-COMP DIM OR 100,000 BTU)
yea ❑Nomap
J Ie read the hazardous tedab requirements Chapter 6.95 of BOILER-COMP BT
it ,fmmlaHealth&Ssfety Code,Seelons25505,25533and25534. I
�//V
stand that if the building does not currently have a tenant,that it b my NEW RESIDENTIAL MECH. Ilpl so, mS'QFf,
roneibility to notify the occupant the requirements which must be at
prior to issuance of a Certificate of Occupancy.
/f�(.1 r
Owner or authorized agent - Date \ 'b '7 Vu
ISSUEDBYZ
OFFICE COPY