23991 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES
LINES - USE BALL POINT PEN ONLY
Building Addreas;iM00�ing Project ntlflntl.nILw
� 1 pETN23991
Wn rB LM: Z. Jo one:
all 5; CITY&CUPERTINO-BUILDING DIVISION
c.ntra Na Lie.N.. APPLICATION ( PERMIT
Architect ¢r BUfLDINGELECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL Y.
Lk.No
QTY' ELECTRIC PERMIT'_ FEE. BUILDING PERMIT INFO
Address: - PERMITISSUANCE ❑ -F] ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(mmmem, APPLIANCES-RESIDENTIAL }QB DESCRIPTION
.ItSccUon 700r0)ofvfsIon3.(the Buelrumand Pro(essi.nsCode,and my
n.1.1.full(.ceand
effect.
yea Y aC'ai rot i'x
PANELS �1,�j(�a Q�VVsyV T
License Ch® LkY
Date Contactor
ARCHITECTS DECLARATION 7074000 AMPS
flO I understand my plans shah housed aspublic records. OVER 1000 AMPS SQ.FT.FLOOR AREA 5/SQ.FT.
Licensed Professional SIGNSELECTRICAL L E ® 9 N
tkCu OWNER-BUILDER DECLARATION —) /' r,'^x 11�a
thatSPECIALCIRCUIT/MISC - 1 t ' il' III^✓ ^ ^ GA••�(l
Zs., Iherebyaso, (Sect Omexempt from the Conoactooa License Law lm the Q y
oo Q (ollowin ichreg irecHon7m1$Businem and Professions Code:Any city or e� I
c.untywhirh requlrnapemilttommtrvct,alter,Improve,demolbh,orrepalr TQ'tP.MEfE1I OR('OLE INST. `�
g� 3< anystmtlure pdorto lie issuance,ahorequlreathe applicant for such permit to POWER DEVICES ATE
f5 XK U file a signed statement that he Is licensed pursuant to the provision of the
Q6 3 p,F
Contractor's License Lsw(Chapter 9(mmmencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
ion 3 lithe Businessand Profemlora C.de)mthal he iaesempttherefromand VALUATION
.....77777 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSW[TC[iESFIX7lJRF5
G applicant fora permit subjects the applicant to a Civil penalty of not morethan
five hundred dollars(8.500).
❑I,as owner of ro NEW RESIDENTIAL ELEGTR SQ.FI. STORIES TYPECONSTRUCTION
P perty,or my employees with wages as their sale
cum
will do the work and theat.m.I,not intended or offered for
Osale(Sec 70K Bull.,and Profeniora Code:The Cmdactola License law
$ does not apply to an owner ofproperty who Wilda or improves thereon,and
EE wh.d...6workhimselforthraugh hisownemployees,provided that such OCC.GROIIP R[S.11NT15'
Improvements are nm intended oroffewd(orwle.I(,howeven thobullding.r
Improvement ieaold withinoneyearofcompletion,lhe owner-bullderwlll have `
tlic*rden of proving that hedid nolbulldarlmprove for purpose ofsale.). QTY, PLUMBING PERMIT FEE
LJ L ae owner of the m FLOOD TONE APN
property,am.70io,lund Professions
licensed PpRMRISSUANCE
contractorsto constructtheLaw protect(Sol.applyta Business and of property
Code: -
The Contactors e.the Law does h apply ct an owner of property thho ALTER-DRAIN&VENT-WATER(EA)
Wild, or Improve thereon, and who mato for each plofects with a
"ffldalc.a licensed Pursuant to the Contractors Lk&P Law. FEE SUMMARY
1_J I am exempt under Ssc. B&P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,COND. SANITARY- ' Y N�
• Owner .Date RECEPIY
WOR"AN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAX Y_ N
❑I hereby affirm that I have o certificateInsurance
of consent to self-Insum,(Sa RECFBT I
cenlfl¢teof Worken'ComperwHon lruunncema¢rtlfled copy thereo((Sec.
3800,Iab CJ GAS GtSYSTEM-1 INC.YOVILEfB PARK FEE Y_ N—
ccIIgM GAS EA.SYSTEM-OVER 7(EA) _ RECEIPfY
Com any furnished. - BUI LDING DI VISI ON FE ES
Certified copy Ls filedwthhereby thcity GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑
Certified copy V filed with the City inspection division, -
CERTIFICATE OF O(EMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE - SEW EIISANTTARYSIORM EA 200FT, Dale Recei Ib
fphissecticm need not be completed If the permit Is forom hundred dollars
(8100).,less.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y— N
Icenl/ythat in the performance ofthe work(.,which this permit is issued,
I shall not employ any person In any manner so as to become subject to the WATCR SYSTEM/TREATING '
worker:Compenatlon Laws.(Calif.rm.. Date PAID
C• Z NOTIApplICE
cat NEW RP9IDWIMAL PLMB. SQFT.' Date Recei tq
Z O NOTICE TO APPLICANT:11,after making this Certificate of Exemption,you
Pshould bemmesubpct to the Workers-Compensation provoll of the Labor TOTAL:
I W Code,you=atforthwith complywlthsuch provisions orlhis permit shall be
W deemed mv.ked. 13UILDING FEE
CONSTRUCTION LENDING AGENCY 7PAID:
'd IherebyafRrmthattherels a construction lending agency for the perform-
Z are,of the workfor which this permit is bused(Sec.3097,Civ.C.) TOTAL:
VO Lender's No.
LL F (.enders Address QTY. • MECHANICAL PERMIT FEE MECHANICALE
OW I certHy that l have read thlsapplicatlnn and statethatthe above information _
IL ismrrect,Iagreetocomplywlthallcityandcountyordmancesandstatelaws PERMIT ISSUANCE
} 00 relating to building construction,and hembyauthodmreprnentatives.fthia
(— Z city to enterupon the aboverrentirmed property for Inspection purposes. ALTERORADDTOMECFL Rxei !ll
(We)agree to save,IndomNly an d keep harmless the City of Cupertino - -
V against liabilities,in gnenb,cosh and expenses which may In any w accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
a al aid City .eque .(the ting of this pe
low AIR DANDLING IINIT(OVER 10,000C III CONSTRUCTION TAX
Signature.(Applicant/Contra to IXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA7ARDnifflAATERIALSOISCLOSURE
Will the applicant or future Wilding occupant store or handle hvardous HEATING UNIT(M 100,000 BTU) Date Recei Iq
Wuterul as defined by the Cupertino Municipal Code,Chapter 9.17,and the
I ealth and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,00)BM •F
❑YesNo
Wllltheapplicanl or uturn building rampant use equipment or devices VENTILATION FAN(SINGLE RESID) - ISSUANCE DATE
which emit hareM.us air contaminants as defined by the Bay Area Air - - -
Quality Mawgemcnt District? BOILER-COMP Q1-IP OR 100,000 BTU)
I Yes g No '
have read the has .see materials requlrementsunder Chapter6.95of BOILER-COMP(OVER 100,000 BM g1
the California Health&Safety Code,Sections 25S05,25533 and 75537.1 PAID
D
understand that if the building don not comntly have a tenant,that it Is my NEW RESIDENTIAL MECH. SQFI -
responsibilitytonotify the occupant of the requirement.which must be ret rJUY/y,(�/�
2Oprior to issuance of a Cenifleate of Occupancy. ���y�
Owner or authorized agent Doh ISSUED BY �/.'�\tea-1
TOTAL:
OFFICE COPY