23615 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Address: . 23615
1 0 22'•D kms. >z �a
one: APPLICATIONIName: aTa CITY OF CUPERTINO-BUILDING DIVISIONConor'eName: LI a: APPLICATION if PERMIT
'` CATEGORY CONTROL
Architect/Engineers BUILDING-ELECTRICALPLl1MBINGM[C[1AMCAL I
t Lk.No:
QTY ELECT RICPERMIT FEE' BUILDING PERMIT INFO
Address: : PERMITISSUANCE' ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that am licensed under provisions of Chapter9(mmmme APPLIANCES-RESIDENTIAL ]OB DESCRIPTION
Ingwith Sedion7000)of Divldon3ofthe Buen and ProfessionsCode,and my -
limnse Is in fuI force and effect. PANELS
Li Datr Class Lich
Date Contractor fou k
ARCHITECTS DECLARATION 201-t000AM15 B e
ZO I understand my plana hag be used as public records. OVER IODO AMPS ' t FffAREA - $/`A7.FT.
HLlceneed Proteselaoal - SIGNS ELECTRICAL •, ■ {
�1LCu OWNER-BUILDER DECLARATION I{,`
E' Ihsrcbyalflmn E
SPECIALCIRCUR/MLSC that l am exempt from the Contractor's License Law for the
pp following reason.(Section 7011.5,Business and Professions Code:Any city or OAT
2F.qQ TEMP.MEfTR OR POL ]NST. E x`71 y
Ir cwntywAlch requiresaperrnitromrutruct,sitar,Improve,demollsh,arrepalr _
iEKa
any structure prior to its figures,also requires the applicant for such permit to POWER DEVICES,
file a signed statement that he us licensed pursuant to the provlelona of the
Commence.oftheLicerea Lew(Cha(Chapter with exempt
Divl- /I VALUA�N�
w W B SWIMMING POOL ELECTRIC 6/LJ'
SOS elen3agfort the
ed Pemptio . Any violation
n of Section
therefrom and _ V.
<� the baant for lbs alleged exemption.a. Any t toga civi of Section nor room
by any OIITLETSSWI'ICHFSFf%711RE5
O
applicant fora permit eubjeNthe applicant loo dull penalty of nor more than
tir� ddollam(S.SOQSQFI. STORI TYPE CONSTRUCTION
NEW RES[DENTW.ELECTRner oftproperty,or my employees with wages as that,solen,wllldothwork endthestrudurebnmIntended or offered for
c 4,Buelnnsand Pmf.auoru Code:The ConlradofsLlconss Iaw
dly to an owner of properly who builds ar Improves thercory and OCC.GROUT' RES.UNITS
who does such work himaeff orthrough his own employees,provided that such
improvements are not Intended or6ffered for sale.IG hmvevep thebuilding or TOTAL:
improv....issoldwithin oneyearolcomp stion,the owner-bullderwill have
tI1C�arden of proving that he did not build or Improve for purpose of sale.). Q'ry. PLUMBING PERMIT FEE FLOOD ZONE APN
1 I_,J L as owner of the property,am exclusively contracting with limnxd PERMIT ISSUANCE -
centrecton 1.construct the ponied(Sec.7044,Business and Profssskra Code:
The Contractor's License Law don rad apply to an owner of property who
Wild. or Improve.thereon, and who comment for such Ino)eda with a ALTER-DRAIN&VENT-WATER(EA)
do a)licensed Pursuant to the Conmdor's License Law. FEE SUMMARY"
(_f I am exempt under Sec. B& P C for thin reason BACK FLOW PROTECT.DEVICE ru 11.11v
DRAINS FLOOR RCOF,AREA,COND. - SANITARY Y N
Owner Date RECEIVE
WORK MAN COMPENSATION DECLARATION FIXTURES.PER.TRAP SCHOOL TAX Y N
❑Thereby affirm that I have o el rt one of consent d epytheum,ora RECEIPT N
cedltlLab o(Workere'Comperwtlonlnuuranm oracertl(led copythereof(Sec. GAS EA.SYSTEM-11NC.40UTLMS PARKFEE Y N
Penc�800,lab CJ
{sollcy p - ftECLMM'X
GAS G.SYSTEMAVER 4(EA)
� Ca�mFany - - BUILDING DIVISION FCB9 .'
I I Certified copy be filed with
the city CREASE/INDUSTRL WASTE INTERCEPTOR PLANCI-IECIC FEE
rL�—J Certified copy b hereby furnished.
hnis city Inspection division,
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE7RAP PAID
COMPENSATION INSURANCESEWER-SANITARY-STORM EA.200FT. Date Recei t#
(Thin section need nd be compiled if the permit Infer one hundred dollars
($100)orl..) WATER IIF.ATFR W/VENT/EL[CTR ENERGYFEE Y N
I certify that In the performance of the work forwhich this permit is issued,
1 shall not employ any person In any manner so as to become wbjed w the WATER SYSITM/TRGTiNG
Worken'CampemaHon Lewsof California.Date PAID
0 Z Applicant NEWRESIDENMALPLMB. SQIrE. Date Rcmi t#
Z O NOTICE TO APPLICANT-. makingthls Cortiflcateof Exemptlan,you
shatld become subject rothe Worksri Compematlon pmvbmru olthe Labor .NOTAL:
N Code,yowronut forthwith comply with ouch provklmamthi.permit.hallbe BU Oe C
LU 9 - deemedrevoked. a,x '
CONSTRUCTION LENDING AGENCY SEISMIC FEE
IL 1 hereby affirm that there le a construction lending agency for the perform- ELECTRIC FEE
M Z ance ofthe work for which this permit Lsissued(Sec.3097,Civ.C.) TOTAL:
V 0 Lender.Name PLUMBING FEE
LL F 1.ender.Address QTY. MECHANICAL PERMIT FE MECHANICAL FEE
O W ImdlfythatlhavereadthBappButlonendpatethattheaboveinforroation
Income.P agree to comply with all city and county ordinance and state laws PERMIT ISSUANCE FEES PAID:
} N relating to building com uction,andherebyautherisempeesentatlvesofthtt
(— Z Lj
to enter upo`the above-mentioned property for bupetionpurposes. ALTER ORADDTO MECH. Da ate` ReCCIPt# -
V to save,Indemnify an rep harmiess the City of Cupertino
esjudgmenb,coatsa pe .which non aAIR HANDLING UNIT(TO 10,ODO CFM) SUBTOTAL:
y in coesTion, ng sPa.
/ 4 - AIR HANDLING UNIT IBonoaM) CONSTRUCTION TAX
q A cont/con, tb� IXFIAUST HOOD(W/DUCT)
Ik
CONSTRUCTION TAX PAID:.
HAZARDOUS ATERIALSDIS URE
Iitheappllcantorfuturel, ldingo=pante orhandlehazzrdous I[EATING UNIT 100,000 BTU)
material as defined by the Cupertino Municipal Cods,Chapter 9.12,and the Date RCCei t#
Health and Safety Code,_Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
. Will the applicant or❑Future building occupant useequlpment ordevicea VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haszrd....ii contaminants as defined by the Bay Area Air
Quality Management District? BOILFRGOMP OMPOR 100,000 BTU)
G� 4 Ye. 1� No , A p
have read thehazz NmaterialsrequirementsunderChapter6.95of BOrLER.CONP(OVER 100,000BTU) • N ' D
the California Health&Safety Code,Sodium 25505,25S33 and 25534. I
understand that If notify
the occupant
nmarequirehave
nts tenant,that it bony NBW RESIDFNDAL MEGH: SQ.FT Jul
rnsponulbilityro notify the onvpant of the requirements which must be met V ss�
prior to L%uanm'of a Certiticateof Occupancy. ` ., y
Owner or authorized agent Date tT I i1V II
TOTAL: ISSUED BY'
OFFICE COPY