23911 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY '
Building Project Identification �rt ,yUes anea{ PERMIT NO.
Building Address: 1' 23911
6S0 ttc�
Dere aces: 1— one:
n CITY OF CUPERTINCL BUILDING DIVISION a'�
Cdntract.rs N.ma: Lie.No APPLICATION /PERMIT. 6 ra�Z
BUILDINGELECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL a
Archited/Enginear, Lk.Nes
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrm:- PERMIT ISSUANCE. ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Thereby af(Irm LIulLmlknsed under prwWonso(Chepter9(commenc- MPLIANCESRE4DENTIAL J08 DESCRIPTIONIngwlth Scdlon 7000).f Dlvldon3oflhe Budnessand Pro(ml.n.Czsdgand my
Lioruen la la full form and effect. PANES �
LlmnClan LIca
Dale• Contractor
ARCHITECPS DECLARATION 301-1000 AMPS .
02. I understand my plana shall be used as public records. OVERIODOAMPS SQ.FT.FLOOR AREA S/SQ.FT.
O
Licensed Professional SICNSELECTRICAL'
6 OWNER-BUILDER DECLARATION
rn'a SP[CIALCBtCUIT/MLSC
]hereby af0rtnthatLmeae5,B firanathBottom
dPrafirwha Llmme Law Any
(o8owingreason.( apion 71Dt5,Bm ftdandr, 1p b, Code:Any dtyit
F� 7FMP.METER OR POLE INST.
�� coysMm hretolap ame,mwreYui alter, aprUv tf mch,erepair
any atmcturetate enc that
he hi a..se pursuant
the
lmsuchperrrdtle - POWER DEVICES
y'µ Ole a Signed statement La (Chapter het 8renead pursuant it the proWbna of the
Oµ Con3ofthe Llcevastawrf.i .Cd.)orthdheth Sedlon7W0)of Divi.
mand
30 the basis
Budnnsand Profmlon.Anyvirlhrthet exempt Lhcrefromany SWIMMING POOL ELECTRIC VALUATION
Q the lican for the alleged u exemption. Angvlola civil
of Section not m re any OUTLETSSWITCHE&FIXTURES
five
applicant Spears IB subjects the applicant Loa tivll penalty of rad more than
five 1,as Owner of the pO. NEW RESIDENTIAL ELECT'R SQ.FT.
I,as owner of the ro STORIES TYPE CONSTRUCTION
�n p ork,aor my is
Wended
e.Theirs ole
compensation,t0KB doth.work,and Cdurctnot Wended or offeredLaw
.vie(See 7614,to aniread owner Prooperty Code:The Contractors herem law
[ $$ don not apply loani.Iorth=gy s Own employilds or mprovesthcrcoryand OCC.CROUp RES.UNITS
0. wprovehe ents.ch am Am intendedorwghhbowne.If,hoee,prwWedildingthat h
Improvement arenot Intendedoroffemdforeak.Il,however, deer illng a TOTAL:
Improvement!sold wlthlnoneyeam(c.mpldbry Iheowner-builderwlllhave '
tlgIlurcien of pmving that he did not build or Improve for purpose of eatJ. QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
u 1,as owner of the property,am exclusively com—i.,wan licenced PERMITISSUANCE
contractors to co.(mct the project(Sec.7014 Rush.and Professions Code:
The Contractor's License Law does no apply to an owner of property who AL7FR-DRAIN&VENT•WATER(EA)
build.or improve thereon, and who contracts for such p(ojeds w.th a FEE SUMMARY
C151 am
pursuant m the Contractors Lt..Law. BACK FLOW PROTECT.DEVICE
I am exempt under Sec B&P C for this reason
OUTSIDE FEES
DRAINS FLOOR RCOF,AREA,COND. SANITARY Y N
Owner Data� RECEIPT p
WORKMAN COMPENSATION DECLARATION
QI hereby affirm that l have a certificate of consent to self-Inure,m a FATURES PER TRAP SCHOOL TAX Y_ N_
certificate.(workers'Compe.ti.nlmu...¢ .mrtifLd.pyth,.f(Sec. RECEIPTp
3800,IabC.) GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y_ N
polq♦ GAS EA:SYSI'EMAVER 4(EA) RECEIPT M
Cany BUILDING DIVISION FEES
Corn
Certified ropy t hcrcbytthe city �� GRPASE/INDUSTRL WASTE INTFRCEP'1L�RFEE
CertPLANCHECK Certified t filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE 7RAP PAID
COMPENSATION INSURANCE BEWER-SAMTARY-5117RM EA.31XRe1'. Date IM
(This section need not be completed If the permit Is for one hundred dollars
entact.rlm.) - WATERHEATER W/VENT/ELECTR ENCRGIIFBE
I certBythat In the pedormanmth
ofthework forwiUchs permit tw
Eased,
�( as
I rlu nm employ any person in any manner n as t.become subjM to the
Workers'Compenwtbnlaws.(GBfornt. Dat WATCfi SYSTEM/TREATING PAI �
0 Z Applicant NEW RESIDENTIAL PLMB. .cel t
Z 0 NOTICE TO APPLICANT:If,aflerrmking this Certificate of E.emptl.n,you —PO'FT'
I— N become should bee subject to the WorkdeComperuallon provisions ofthe Labor TOTA
Ix Code,you muotforthwith comply with such provisions,ortht permitshall be
W j deemed revoked.
a CONSTRUCTION LENDING AGENCY SEI$ FEE
I herebyaflmothal there to construct.kndingagenty forlhe per!. ry ' ELECYRIC FEE
D Z anmoftheworkrorwhkhlhtpermit hoed(Sec.3097,CIv.C.) TOTAL:
;02 IaMele Name P ING FEE
. IL I— Lender's Address QTY. MECHANICAL PERMIT FEE CHANICAL '
0 W Icertlfylhat l have madtht appllcationand datethattheab.ve Information
6 le correct.I agreeto comply with all cityand county ordlnanm,and date laws PERMIT ISSUANCE FEES PAID:
} fA relating to building construction,and hereby aulhorlu representatives of this
H Z city to enter upon the abovo-mentloned property for Inspection purposes, ALTERORADDTOMECH. Date - ReCCIPtR
VMPU N a 10 Save, fecudfy and keep harmless the City of Cupertino
ago the.,' dg els, sand expensnwhich may in nyw yacerue AIR HANDLING UNIT 10,ODOCPM) SUBTOTAL:
rut CI n . fthe ntl gaf this perrnl
AIR HANDLING UNIT(OVFR 10,gp CFM) CONS% CTION TAX .
lin ureo p nV racmr ate— IXHAUSTHOOD(W/DUCT) CONS UCTION TAX PAID:
AZARDOUS MATERIALS DISC RE
Will .app cant orfuture building occupant storsor handle hazardous HEATING UNIT(TO 100,000 BTL)
Lariat as defined by the Cupertino Municipal Code,Chapter 932 and the ate Recel tN
1 all Ynnd Safety Code,Section 25533(a)7 HEATING UNIT(OVER 100,D00 BTU) TOTAL:
Rat'the applicant or rare building oempart sex equipment or device VFNOLATION PAN(SINGLE RESID) ISSUANCE DATE
which emit haardous air conlamtante as defined by the Bay Arca Air
Ouillty Management Mind? BOILER-COMPOFD'OR100,000BTU) p 1 D
- QYea - Mi
"read the hazy moo,oua materials requlrcment under Chapter 6.95 of BOILER-CAMP(OVQt 100,00007V)
theaCode,SMlone3 O5,25533and3S534.1
understand that lithe building does not currently have a tenant,that 11 dmy NEW RESIDENTIAL MECIL SQ.FT VV 2' 1992 1(Tea�
asp-Ashility to edify the occupant of the requirement which at be sect y Ix7s7�
pdor to Issuance of a Cenificatc.f O.pancy. C1l Y
V I OF Cilrcnwv
� �-
Owner.r authodzed agent Date ILSSUEDB .
TOTAL:
OFFICE COPY