23478 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Buildbg Addma 23478
k O.1�o L.t� IA�}F.
w . )ere: _ \ one.
¢j5--W?_D800 CITY OF CUPERTINO-BUILDING DIVISION
Contractor'.Name: LIc.No: APPLICATION 1 PERMIT
1L3 BUILDING-E.ECnUCAI.PLUMBINGMEChiAMCAL CATEGORY CONTROL#
Archaeet/Engiker, Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: i.
LICENSED CONTRACTOR'S DECLARATION PERMATISSUANCE El "y1:1
I hereby affirm that lam licensed under provisions of Chapterg(commenc. APPLIANCESRESIDENTIAL 00
1
I ng with Section 7000)of Dividm%3 of the B usl nese and Professions Code,and m
it. is In full to Seca affect ,f'S42Z3 PANELS
LI=Cb. Lk.# 'Y' -
Date Contractor
ARCHITECTS DECLARATION 201-100DAMPS
pkQ{v�cc0 O' I understand my plana shall be used u public records. OVER 1000 AMPS 5� �ARFA w . S/
6� - I SIGNS ELECTRICAL ' N
Licensed Professional / p . ••
OWNER•BUILDER DECLARATION SPECULCIRCUIT/MISC yVy
Zp thereby e(Brm that[cent exemptfromthe Conl raciols Li.nse law for the
02pap following reeon.(Section 70715,Business and Profmion,Code:My city or (�
TEMP.METER OR POLE INSI. DATE ] �w
�0G5� county which requlrce a permit b construct,alter,beprove,demolish,or repair
�[t5a any structure prior to its Issuance,also mquG.the applicant for such permit to POWER DEVICES J
K E V file a signed statement that he W licensed pursuant to the pruvlsioro of the
3w1. Contractors License Law(Chapter 9(rommencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
HBO"J at..3ofthe Budnessand Professio.Cods)or that he h; VALUATION
6.5 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCIdFSFIXIIIRFS 7
apphmnt(ora permit sub)eci.the appikanl to a civil pemityof nm oerethan
live hundred11adollies
erofth5 pro NEW RFSIDENIIALELECTR SQFT, STORIES TYPE CONSTRICTION
�j I,as owner of othe
property,or he employees with wage sa there sole
X70, mm(Sac.744,wllido..nd Pr anathesCode: heCis Wended or offered for '
q dab(Sec. ppy to an
df property
Code:The builds or Improves License law
does not apply loan owner ofthroug his onempoymprwvided that such
OCC.CROUP RES.UNITS
whodoeeeuch work hlmfeBorthrough hieownemployees,provided lhatsuch -
Improvemenharenotintendedoro(feredlorsale.If,however,lhebullding orT
Improvement bsold withinomyearofmmplmbn,theowner-bullderMll have
thiLlturden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE .
LI L as owner of the property,am exclusively contracting with licensed bT.00D 7DNE APN
centractoes to comlruct the project(Sm 7014,Business and Profeelum Code: PERMIT ISSUANCE ,
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-
buBds or Improv.thereon, and who motracis for such plokcb -
with a WATER(EAT
onBETIactor(s)It...d pursuant to the Com.ciors Lt...Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. 8&P C for this.aeon _ OUTSIDE FE
Owner
DRAINS. ROOF,AREA,GOND. - SANITARY Y N—
Date RECENT M
r�aF WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y_ N
Ip1I hereby arf m that I have o ld cone of consent b pythsu.,ora - RECEIPT#
d00,La eo/Worken'Compe.aHonl.unn.ora.rtBied copy lhenrof 6ec. GAS FA.SYSTEM-1 INr_4OUTLETS PARKFEE Y N
3#00.Lab CJ
Policy#- ' GAS EA.SYSTD4,OVER#(EA) DING DIM
Cam any - - BUILDING DIVISION FEES
[�Certlfled copy is hereby tthehetl. - CREASE/INDUSTRL WASTE INTERCEPTOR - PLANCHECK FEE
'♦�ICenmea copy b filed withh lM city impaction division. _ .
CERTIFICATEIXEMPNI RWORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE URAANN CE SEWER-SANITARY-STORM EA 2NFT Date Recei t#
(fhbxatlon need n.be completed tithe permit lslrroro hundred dollars
($100).elee.) WATER HEATER w/vpxr/F1.ECTR ENERGY FEE Y N
I enrtifythat in the performance of thework forwhich this permit is Issued, —
I.hall not employ any person In any manner u.W become subject to the WATER gYSfEM/TREATING
Workeme'Compensatlon Laws of California.Date PAID -
Z Applicant NEW RESIDENTIAL FILMS. SQ,FT. Date Remi t#
Z O NOTICE TO APPLICANT:If,after making this Certl(kate of Exemption,you
N should become subject to the Workers'Compersatbn provlsbroof the Labor TOTAL:
Code,you at forthwith comply with such proviabm mthl.per e ft shall be
deemed revoked. BUILDING FEE
Q. GCONSTRUCTION LENDING AGENCY - SEISMIC FEE
2 I hemby alBrmthat there is a construction lending agency forthe perfarrury TOTAL: ELECTRIC FEE -
u an.of the work for which this permit Is Issued 3097,CIv.CJ
V Q + Tender's Name - PLUMBING FEE
LLF- c Lender.Addem QTY. MECHANICAL PERMIT FEE MECHANICAL FEE ^^
OW ImrtlfythallhavemadthsappUmtlonandelatelhatlheaboveinformatlon
1 lscorrect.l agree tocomply with all cityand county ordinances and elate laws PFRMITISSUANCE � �� FEES PAID:
} W relating to building romtuction,and hereby authodzerepreentadv.oflhls
1.— Z city to enter upon the above-mentioned property for Wpetlbn purposes. ALTER OR ADDTO MECH.
— (We)agree to save,tndemN(y an d keep harmless the City of Cupertino - Date Recei t#
agaJJJJJJinnnnBB0eeeseeet Bab111tb;/ndgment.,cedeand caper..which may In any w.yac.ue AIR HANDLING UNIT CTO 10,000 CFM) SUBTOTAL:
ag tsald aequ`n.of the granting of this permit,2/� AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
gesture of Applicant/Contractor ` II// te� EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wllltheappli.nt or future budding occupant store or handle hazardous HEATING UNIT(T0100,ODO BTU)
materlalacam
e0d by the Cupertino Municipal Code,Chapter 9.12,anathe Date Retel t
Health and Safety Code Section 25532(a)2 HEATING UNIT(OVER 100,000 BTU) TOT&
❑ Yee �k No
Will the applica nt Jr(umre bu tieing occupant me equipment or devlms VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit ham rdous air contaminant.as defined by the Bay Area Air ,
Jality Management District? BOILER-COMPOM'OR100,0001171) F' A
Yes �No VITT CC
have read lheh us materials requlrcmnnb underChapbr 6.95 o! BOILER-COMP(OVER 100,000 BTU)
the California Health&Safety Code,Sections 25505,75533 and 2:534.1 APR 1 .
understand that if the building does nM currently have a tenant.that It is my NEW RESIDENTIAL MSCI I, 4TOTAv' I'
responsibility tooto notify tM1c occupant of requlremente which must be �` Cl.r 1999a(�
pd issua e a he ocuo(Ocoupa ncy, (tel\`fie y`J
� � agent
(J°vner or authorized agent fete aISSUED BY:
OFFICE COPY