23681 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Bending Addrtaa: 2,3681
w
lie . sous: ane:
CITY OF CUPERTINO-BUILDING DIVISION
Ca"` d°' '""' qLk Na: APPLICATION if PERMIT L
f CATEGORY CONTROLY
Archlted/Englnser. Lle No: BUILDING-ELECTRICAL-PLUMBINGME LAICAL
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
IFereby affirm that am licensed under provisions of Chapter 9(mmmmc APPLIANCES-RESIDENTIAL JOB DFSCRR'DU -
tngwlthSect1on7OOD)of Dlvlsion3afthe Rusin and Pmfe onsCode,andmy
Ii cense lalnfun f9rce Ll all c 7 5 PANELS/ I., )pv
Date Claw%r'��, LACY J J (/ Ws/`�-
Date ARCogra
or
CHII'ECl'S D�CLA ATION� 201-IOW AMPS
q9Z I understand my plane shell be used as public record& OVER1000AMPS SQ.FT.FLOOR AREA S/SQ.FT.
0 COC.
E tj Licensed Professional SICNS ELECTRICAL
OWNER-BUILDER DECLARATION SPFCIALCBtCl1IT/MISC
p.,�n•� Ihercby affirtnihatlam exemptfmmlhe Contndor's Licenalawfmthe
o�n o following reason.(Serion 703M,Business and Professions Code:Antl or
�zt"'ty county which requires a permit to construct,alter,Improve,demollah,or repair TEMP.METER OR POLE INST.
7 anyebuctumpdortolbleuaMe,aWnquirestheappUmntforsuch permltto
ROWER DEVICES
0. file a signed statement that Ile la licensed pursuant to the provlelmu of the
00.I. Contndora License Law(Chepler9(mmmendng with Section 7000)of Divi-�O"J don 3o(the Buelneaaand Professions Code)orthat he bexempt therefromand VALUATION
SW)MMINC POOL ELECTRIC
the basis for the alleged exemption. Any violation of Section 7MIS by any
C applicant fora permit subjetetheappncant too civil penalty of not more than OUTLETSSWITCIIESHXTIIRFS
five hundred dollars(¢500).
�n ❑i as owner ofthe property, NEW RESIDENTIAL ELECTRSQFr. STOWES TYPECONSTRIICTION
, p perry,or he employers with wages r there sok
mmpewatlorywnldothe wmkandthes Code:
hes onractoet intended a censeofferd for
Law
O does notale(Sec.apply
to M essow er f property
rops ty Co buildsThe Crimpersthe mus Law
who doessuch
such oak owner of(prough his o nem orimprwwthereoryand OCC.GROUP RES.UNITS
whodoementsawork hlmse dedof or rwgrad(m e.If,
praise uildithat such
bnprovementsarendintended earofrcdforeion,th cwmereyfflder ill have TOTAL:
im.rurde ntissatidof proving
within he did robed porirnthee(or purpose
of sale.).
tfLj L as owner
of the p he property,
a bund orlmprove(acting oae livens. QTy, PLUMBING PERMIT FEE FICOD 7nNE APN
cru 4 er owner of the Pmperty,am exclusively Business
and
licensed PERMIT ISSUANCE
mntndon to construct the project(Sec.apply
Business and of pro ons Code:
The s or improves,
License law does not apply tct an owner I property who ALTER-DRAIN At VENT-WATER(EA)
Wilds or 1)ImRse thereon,and who costae, !m such p(o)em with a FEE SUMMARY
cq➢1(�dor exempt
under
to the Contndo/s LicenseLaw,for
BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sae B 4 P C (or ehk reawn
OUTSIDE FEES
DRAINS FLOOR,RCOF,^AREA,COND. SANITARY Y N
Owner Date r _ RECEBeTp
,..A WORKMAN CO MPENSATION DECLARATION �gcpq.°,pr j -, SCHOOL TAX Y_ N
pYI herby afnm,that I h.ve.mtlinnte a(cancnt m sem-Inaom,ar a `"f"T RECEIPT/'
dnlfinte°fWorkers Compensationlwurance wa ttrtl(kd ropy themaf(Sec.
3800,LabCJ ^� 2_ GAS EA.SYSTEM-LRJC.d IjD,EII'� , PARK FEE Y N
C. a ,CAS EA. I iRECI]I'TM
Com anv BUILDING DIVISION FEES
❑pCcrtined copy ere y(umlahed. CDUSIRL I
' �ertlfiM copy h filed with the city inspection division. PLANCHGCK FEE
'EG
CERTIFICATE OFEXEMPTION FROM WORKERS' — OREASETRAP PAID
COMPENSATION INSURANCE
(rhissedionneed nor becompleted lithe permit laforonshundred dollars SEWER-SANITARY-STORM EA.20OFT. Date Recel t#
($100)or Ing.) WATER HEATER W/VENT/M. TRaENERGYFEE Y N
I certify that la the performance of the work forwMch this permit b lamed, —
1 shall not employ any person In any manner so as to become subject to the WATER SYSDM/TREATING
Workcre'Compenwtlon laws of Callfomh.Date - PAID -
Z Q NO7ICETOAPPLICANT:Il,after making this Certificate of Exemption,you NEW RESIDENTIAL PCMB. SQ}T. Date Recei t#
should become subject to the Workers'Compensation pmvlelons of the Labor TOTAL:
y Code,you=at forthwith comply with such provisioner or this permit Mail be -
W > deemed revoked. BUILDING FEE
a c
CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm that them k a construction Lendingagency for the perform ELECTRIC FEE
Z ance of the work"(or which this permit is Issued(Set.3097,Civ.C.) TOTAL:
02 Landers Name PLUMBING FEE
LL F Lenders Addreae QTY I MECHANICAL PERMIT FEE MECHANICAL FEE
O Ill Icertllythatl have madthlaapplicatlonand datethat theabove Information
fl lamrred.l agreeto complywith an cltyand county ordinances and state laws PQ(MITIS5UANCE• FEES PAID:
>. N relating to building construction,and hereby authorize representatives of this
F Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH. Date ReceI t#
_ (We)agree to amkee
save,Indenlly an d p harmless the the City of Cupertino F
against llabWties,judgments,cops and expenses which may in any way accrue AIR HANDLING UNIT(TO IO,ODO CFM) SUBTOTAL:
against old City in consequence of the granting of this permit AIR HANDLING UNIT(OVER 10,000 CIM) CONSTRUCTION TAX
Signature of Applicant/Contnctnr Date EXHAUSTHODD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or hand Is hazardous HEATING UNIT(10 lOD,ODO BTU) Date ReceI t#
nutedaI as de0ned by the Cuperdnm Mmddpal Code,Chapter 9.1 2,and the - L
Iiealthand Safety Code lion 25532007 HEATING UNIT(OVER 100,000 BTU) TOTAL: AS
RYa
ill the appBolit rfu re building acm pant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit haradous air cents mmanta as defined by the Bay Area Air PAI
Quality Management District? BOILER-COMP OLE'OR 100,000 BTU) IC P'a '
4 Ya f No
havcread[heIn th&SfeVCrteSa t..255nbundcrChapter G95of BOILER-COMP(OVER 100,000 BTU) 1g 1992
theerstan nh Health ASafety Code,Sections25505,ve a tenant,
1 JUN
u spend lid[hal n tifyhe the ing doesoccupant of t currently have which=at n la my NEW RESIDENTIAL MECH. SQ.IT
responsibnity to ndlty the occupant d the requimmenta which must be met
rtm lsseanm daCertlfic of cupancy. 6•���92 CITY UI' 'j"" �
net or authorized ages Data TOTAL: ISSUEDB)'
OFFICE COPY