23674 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Procd Identification PER.MITNO.
Buliding Address: .23674 n 3 6 7 A
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w yob_d 9CITY OF CUPERTINO-BUILDING DIVISION 5',j L 47
. C^^tr n%• •^e: Lle.No: APPLICATION /PERMIT ((JJ —(
—1'5129'15 BUILDINGELECTMCALPLUMBINC-MECFIAMCAL CATEGORY CONTROLIf
Arch ten/Engineer. &7 Lk.Na:
QTY ELECTRICPERMIT FEE BUILDINGPERMITINFO
Address I'ERMITISSUANCE � ❑ fSn ❑
Lm that ED CONTRACTOR'S pr DECLARATION -FIO
I Mrebyaffn7").lamllcen3.fth underprovisions
c,.A.ns of Chapter9(ammrnc- APPUANCESRESIDENTIAL ]OB DESCRII'1'[ON
Ingwah Section7000)of Dlvision3ofth Bt,l essand Pl slona Code,and my /
license is u f.e— and dfM. 7 PANELS P /
LlrenstCla®('-3 Cant L
Date CHITEC"r 2011000 AMPS P\'
UP TO 200 AhIES
A.AH 11 CI'SDECLARATION OVERiOOOAMPS SQ.FT.FLOOR AREA S/SQ.FT.
0]. iunderstand my plan shag be used as publlcremrds.
OCC
U Licensed Professional SIGNS ELECTRICAL
w OWNER-BUILDER DECLARATION
In Fn SPECULCIRCUIT/M15C
t.., owing r asm.(Salam 1,5,B from the d Pmfesakm,censc law for the
O O M 8 following reason.(Section permit
Businem and PImprove, Code:Any copfty it TEMP.METOL OR POLE INST.
Z
county which requiresa perMttomnstrud,alter,Improve,demolish,orrepair
gF`3QN anystructure prlorto its Issuance,also mqulreathe applicant forsuch permit to
Ep5y rN1 file a signed statement that he Is licensed pursuant to the provisions of the POWER DEVICES
Contractors License Law(Chapter9(commencing with Section 7000)of Divi. y-WIMNUNC POOL ELECTRIC 5 VALUATION
O Aam3 ofthe Buslnessaad Profexlom Code)orthat bets exempttherefmmand the basis for the alleged exemption. Any violation of Sectio7M15 by any OUTLETSSMICHESFIXTURES
applicant for a permit subjects the applicant to dvil penalty of n^t rrore than
A. five hundred dolWa($500). NEW RESIDENTIAL ELECTR SQ.FI'. STORIES TYPE CONSTRUCTION
7¢ F�I,as owner of the property,or my employees with wages as their sole
compensation willdome work andthestrudure is not intended or offered for
5�O vie(Sec.704d,Business and Professions Code:The Contractors Llrenx law
[�S$ does notapply to an ownerof property who Wilds or improvesthemon,and OCC.GROUP RES UNITS
CC whodornsuchworkhrreadforthrwgh hisown employees,provided thatvch
Improvements are not intended oruffered forsale.If,however,thebullding m TOTAL:
Improvement tssold withmoneyearofcompletion,the owner-0uBderwlll have
thrden of proving that he did nes build or improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOODlONE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors toa struct the project(Sec.7044,Business and Professions Code:
The Contractor's License law does not apply to an owner of property who
Wilds or improve•thereon,and who contracts for such pkojects with a ALS-DRAIN&VENT-WATER(FA) �3
co ctor(s)licensed pursuant m the Contractor's License Law. FEE SUMMARY
U I am exempt under See B &P C for this reason BACK FLOW PROTECT.DEVICEOUTSIDE EEES
DRAINSFIOOK ROOF,AREA,GOND. SANITARY Y_ N
. Owner Date RECEIPT
a RECPf N
K
WORMAN COMPENSATION DECLARATION FIXTURF_S PER TRAP SCHOOL TAX Y_ N
1 hereby affirm that I have a anlBote of consent to self-insure RECEIPT N
1 ateof Worken'Compevatimly mnmmaaAffiedmpythereof(Sec. CAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,lab CJ y'33� —9 — RECEIPTA
Polity N GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
Com sons G,'Certified copy copy ts hereby fumished. PLANCHECK FEE
n Certified copy is filed with the city Wpectlon division. GREASE/INDUSIRL WASTE INTFRCFPTOR
IYC` CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.20GFT. Date Remi of
(TFlssedlon need not be completed If the permit isfm one hundred dollars
(SIMorless.) WArER IMEATER W/VENT/FZECTR ENERGY FEE Y_ N_
I m"ythat in the performance of the work for which this permit Is Issued,
1 shall not employ any person in any runner an as to become subject to the WATER SYSTEM/TREATING ` PAID
Workers Compensatiantawamf Gbfornla. Date
OZ Applicant NEW RESIDENTIAL PLMB. SQFT. Dale Recei tq
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should become subject to the Workers Compensation provision•of the Labor TOTAL:
T Code,you must fort hwith comply with such provisions or this permit shall be BUILDING
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Ihereby afOrmthat them Is a comtrunlon Lending agency for the perform- TOTAL: 5 ELECTRIC FEE
M Z aha of the work for which this permit Is Issued Ger.3897,civ.C.) ELECTRIC FEE .S
V O lenders Nacre
U. H LenderaAddreas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U l mdlfythatl have read thisapplicatlonand statethat theabove Information
O W iscorrect.I agrecto comply with all city and countyordinancesand state laws PERMIT ISSUANCE FEES PAID:
} (L relating to Wilding covtmctlon,and hereby authorize representatives ofthts
`A city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADDTO MECH.
? (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Reeeip[A
V against liabilities,jrdgment dexpenses which may In any way accrue AIR HANDUNG UNIT(TO 10,000 CFM) SUBTOTAL:
agai Id City In con enc Pith Mina of this permit.
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
sig urealApp tmdor Date EXHAUST HOOD(W/DUCE) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applla at or future building occupant store or hand to hazardous HEATING UNIT(TO 100,000 BTU) Date ReceI til
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
Iieahh and Safety Cod r,$ectloa 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑yeao
Will the applicant o future building part use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUAN DATE
which emit harardousair contaminants as dellned by the Bay Area Air P A
• Quality Management District? BOILER-COMP QHP OR 100,W0 BTU)
4Y:s No
havereadthebaza osmaterialsrequirementsunderChapter6.95of BORER-COMP(OVER IW,000BTU) AUG :- 6 1992
the California Health&Safety Code,Stolons 75505,75533 and 255.534.I
undentxndt)utifthebulldingdoesnotcurrentlyhaveate^anLthatitismy NLWRFSIDENIALMECH. :Q.1.7
resnsibllitytonaifytheocmpantofthemqulmmentswhlchmustbemdt
r to Lssuana artif aeof Occupancy. 9af CITY Ur L,ur CT11114V
s
%
ncr or authorize ent / Date ` TOTAL: ISSUED BY:
OFFICE COPY