23989 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building pram IdentificationPERMIT NO.
Building Add � _ L-ODP 1 - 23989
wnerPhone. APPLICA DON SUBMI I I AL DATE
CUPTc CITY OF CUPERTINO-BUILDINGD(VISION '?' ,�
C °�;N�a — Lk. o: APPLICATION / PERMIT L-iV:7
. BUILDING-ELECTRICA4PLUMBINGMECI IANICAL - CATEGORY CONTROL#
ArchBect/Engineer.- Lie.No:
QTY ELECFRICPERMIT FEE. BUILDING PERMIT INFO
Adtlreae: PERMITISSUANCE �.� 1:1 y O 1:1LICENSED CONTRACTOR'S DECLARATION
I hereby lvsioo3 ftheunder ofChapur Csslons9(comm. APPLIANCES-RESIDENTIAL JOB DESCRIPTION
irgwlthose.hSectfon force andafelct. ofthe Buslnessand P.IeaeioneCode,and my
Liters b in full force and tc.N PANELS
Data Claes Llc#
Date - Contractor UP TO 200 AMPS
ARCHITECTS DECLARATION 201-I000 AMPS
0'Z, I understand my plana shall be,used as public records. OVER 1000 AMPS Q..rr.f100^R AREA. $/:4.FT.
Fi L�L Licensed Professional SICNSELECTRICAL `.'„\ E ' E b B
<6 OWNER-BUILDER DECLARATION �!"Y
SPECIAL CIRCUIT/M15C'
z Iherebyallrmthatlam exempt lromthe Contnctore License Law for the
p countygmowquirreap 7mttocoslness and Proprove, Code:Mydty or r
O'21-.ppp TEMP.METER OR POLE INSf.
ER
P�q u1stme ichter,mrylrtsa issuance,mso truct requinath, apmvet fors ch,ormatto - J , /a�a-a
pG37: any atrutlumtatemenpriorto tshat he
lLw rcqulmsuant t the provisions of
POWER DEVICES DA E I yG
floe a signed statement that he V licensed pursuant[o the provisions o! the
3w�•, ContnRor'e Llcame Law(Chap[er9(cernme.ciagwith Settle.7000)of Divi- SWIMMING POOL ELECTRIC - VALUATION
SOS elon3o(lhe Businessand PrefesslonsCedO orthst he is exempt therefromand
65•i the basis for the alleged exemption. Any violation of Section 7MIS by any OUTLETS-SWITCHES-FIXTURES
applicant lots permit subjects the applicant to a civil penalty of not morethan
flue I,ase, dalhrshepr. NEW RESIDENTIAL ELDCI SQ.FI. STORIES TYPE CONSTRUCTION
❑I,as owner of of property,or my employees in with wages r their vole'
.mpenea 0K w111dothe work and the swdurch not intended or offered for
❑ sale(Sec.apply
Buanow owner
of property
Code:bulds or Improves
Lt.herame Law
$ docs notapply torn owner ofp rough whonemporlmproovided.Ruch OCC.CROUP -RFS.UNITS
.he doneuchwork himadlorthrough his ownemIf honv,providedthat gor
Improvent usold iniftone narofcomplean,the mener-b older ill have T
Improvementbsold withinomycaro(compldion,chs°wner-bulWerwlll have
IFl,,Ilurden of proving that he aid not build or Improve for purpose oleale.). QTY, PLUMBING''PERMIT FEE FLOODZONEAPN
Lj L as owner of the property,am exclusively..trading with licensed PERMIT ISSUANCE
contractors to.retrud the pro)eci(Sec.7044,Business and Professions Code:
The Contra mr's License Law does out apply to an owner of property who ALTPR•DRAIN&VENT-WATER(FA)
Wilds or Improves ther.n, and who contracts ct
for such p(o)ea with a
cgDlfadors)Ilconeed pursuantmtheContrador'sLicense Law. BACK FLOW PROTECT.DEVICE ] FEE SUMMARY
LJ I am exempt under Sec B&P C for this reason
DRAINS.FLOOR ROOF,AREA,GOND. SANITARY Y N
• Owner — OUTSIDE FEES
Date RFLFIPf M
WORKMAN COMPENSATION DECLARATION =9Y51TM-0VFR
R TRAP SCHOOLTAX Y N
❑1 hereby a(!trm that I have o Insurance
of comets to copy
tis,.,oraRECEIPT Y
cenl(Icate o(Worken'Comperuatlonlnuranm oranrtlfled copy tM1er.!(E.. TFM1 ING.4 DITILE'S PARK FEE Y_ N
3800,Lab C.)
Policy# ITA4.OVER 4(EA) RECEB'T#
Com nBUILDING DIVISION FEES
�Certl(Ied copy EM1ereby rvmlehed. LISTRL WA517i INTERCEPTOR PLANGI-IEGK FEE .
❑Certltled copybfiled wlththe dty irupectlon dlvislon.CERTIFICATE OP EXEMPTION PROM WORKERS' P PAID
COMPENSATION INSURANCE ARY-S ORM EA XIOFT Date Ret:ej tq
(Thor section need net W completed lithe permit is fee one hundred dollars
(5100)mlWATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Lrtify that in the performance ofthe work(orwMch this permit is issued,
1 shall not employ any person In any manner so as,to become wbjed to the WATER SYSTEM/TRFATINY)
Workers'Compensation Lawsof California. Data
PAID
O Z Applicant - NEW RESIDENTIAL PLMB. �.Fi. Date Recei t#
Z O NOTICETOAPPLICANT:If,after rmkingnhisCertiticateo(Exemptlan,you
I" should be..sub)eet to the Worken'Comprnxtiaa provislotuof the Labor - TOTAL:
N Code,youmuetforthwith.mplywhhsuchprovbiomorthlsperatshallbe BUILDING FEE
deemedrevoked. I
IL 0 CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Ihereby affirm that there is a.netmetion lending agency forthe perform, ELECTRIC FEE
Z an.of the work for which this permit he Wued(Sec.3097,Civ.C.) TOTAL:
V O Iandar's Name PLUMBING FEE
IL Landeranddreas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Im.i(ythailhawmadthBappllcationandoatethattheaboveln(ormatlon
G b.rmd.Iagmato Comply with all city and county ordinances and mate laws PERMITISSLIANCE FEES PAID:
>. relating to building construction,and M1erebyautherhompressntativesofthis
)— city to enter upon th..Wve-mentioned property(orlrapttHan purposes. ALTFRORADDTOMECH.
Z Date Ri ttl
V _ (We)agree to save,Indemnify an d keep harmss eceF
lethe City of Cupertino
against liabilities,ydgrnente, and expenseswhlchmayln anyway a AIR HANDLING UNIT(TO 10,ODO CFM) SUBTOTAL:
a uln
City 1.
use
(the grant) this permit -
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
slgnalureo(Applicant/Contractor W Fuusrli000(w/Dlxn CONSTRUCTION TAX PAID:
HAZARDOUSRIALSDISCLOSURE
Will the applicant orfutue,building occupant store or handle haaxrdous HEATING UNIT(TO 100,000 BTU) Date Rete) tic
material as defined by the Cupertino Murddpal Code,Chapter9.12 and the
health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOT
RYes Ir�—,1 No
IIIIhea pplicant crfunum W llding occupant use equipment or devices VFNILATION FAN(SINGLE RESID) ISSUANCE DATE
a
which et havrdoue air romernin.etsas defined C bythe Bay Area Air P A 0
. Quality Management District? - BOILER-COMP OHP OR 100,DW BTI) ,
4 Yes No
have readtheh.ar No t..nder Ch.pter6.95.f" BOILER-COMP(OVER 100,000 BTU) 'JUL �o ����
the Califomla Health&Safety Code,Sections 25505,25533 and 25534.1.
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.Fr
.potaibility to ruxify the occupant of the requirements which at be met
prior to issuance of a Certificate of Ompancy. CITY UUl- UUrCY'j .lam
Owner or authorised agent Date - ISSUED BY7a/� / -�•/=J••!�"_
TOTAL:
OFFICE COPY