23709 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Bulldin Pm ed Identification PERMITNO.
"°"d'°BAddro" 23709
/��G IA s�
sorer,aams: one: q
5 eye 1 —LIC CITY OF CUPERTINO-BUILDING DIVISION
Contndor',Name: Lk,Nm. APPLICATION /PERMIT
Architect/Engineer.
BUILDINGELECTRICALPLUMBING-hfEC}iANICAL CATEGORY CONTROL N
Lie.Na;
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PTILMITI55UANCE E
by LIC ENS EDCONTA under rDECLARATION
[heh Sectio 7O that D)of Di siolicen3afth. erprovlsionsoffe aonr9(commrnc APIsWANCESRESIDENTIAL JOB DESCRIPTION
Ingwlth5ect1on7000)ef Dlvielan3o(the Buelnessand Pro(eWoneCode,and my /I��
Manu Is In full(ora and effect. PANELS
�ar` �
Llanse Claes LION J
Data Contmcwr
ARCHITECTS DECLARATION 201-1000AMPS
M2 I understand my plans shall be used as public reanL OVER I ODO AMPS
il �SQ ARI 5/SQ.IT.
O I?LL
Licensed Pofess
rlm al SIGNS ELECTRICAL ED N
6� OWNER-BUILDER DECLARATION SPFGIALCIRCUT/MISC f T E Ry,� Ihcrebyafl.that l am exempt from the Contractor's
7 License law froths
following reason.(Section 70715,Business and Professions Code:Any city or TEMP. OR POLE INST.
O
r� cauntywhlch requlre,a permltrocorutrud,alters Improve,demolbh,orrepalr
anystmdurc prlorrolb lesuance,alaorcquircetheapplicant(orwCh permit to POWER DEVICES �-
file a algned statement that he is licensed pursuant to the provisions of the
0µI1.. Contradoes License Law(Chapter 9(mmmancing with Section 7000)of Divi. SWIMMING POOL ELECTRIC
BOJ s1on3ofthe Bustnessand Profe.ioro Code)mrthathebexemptthomfmmand VALUATION
.••7777 the basis for the alleged exemption. Any violation of Section 7071.5 by any N
O
applicant fora permit subjects the applicant to a civil penalty of not morethan OUTLETS-SWITCHES-FIXTURES
flue. OB. NEW RESIDENTIAL ELECTR SQFI'. STORIES TYPE CONSTRUCTION
�a ...=.f of the property,or my employees with wages as their sole
Co tion,w111dotheworkandlhestructurelarwt Intended or offered for
O sale(Sec.7016,Businea.and Profession,Code:The Contractors License Law
does not apply to an owner of property who builds or Improves thercoo,and OCC.GROUIs RES.UNITS
who docs such work himself or through his own emplmyas,provided that such
Improvements are not Intended or offered for sale,If,however,the building or TO
Improvement lswld within one yearo(completion,the owner-bullderwlll have
t en of proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE
MNI,as owner of the property,am exclusively contracting with licensed I•T-OOD?ANE APN
contractors to construct the project(Sec 7044,Business and Professions Code: PERMIT ISSUANCE
The Contractor's License Taw does net apply to an owner of property who ALTER-DRAIN&VENT•WATER(fLU
builds em or Improve,themor,and who contracts for such p(o) with a FEE SUMMARY
cgal(adorW licensed Pursuant to the Coruxotrs License Law. BACK FLOW PROTECT.DEVICE
Ll l am exempt under Sec. B&P C for this reason
OUTSIDE FEES
at Date
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
'Tun
WORK MAN COMPENSATION RECEIPT N DECLARATION PER TRAP SQ'IOOLTAX Y N
I�l hereby aftbm that I have• e of consent tonau
self-In,a FIXTURES a RECEIPT N
ccm0l1.1,C) orken'Compewtlan lmuranliuunna ora artlllad copythemo((Sec. GAS EA.SYSTEM-1 INC.4 OUTLETS PARK FEE Y N
Poli N GAS,EA.SYSTEM4)VER 4(EA) RECEI'Tp
Ca
Policy
BUILDING DIVISION FEES
I ICemiOed copy is herebytum.city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CertBled copy Is filedhere with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA,200PT. Dale RfCCi IN
(Thi,section need cad be completed lithe permit la for one hundred dollars
rnI0)ocertify
I certify
tha in HEATER W/VENT/ELECTR ENERGYFEE Y_ N
t the peda
armanof the work forwhlch this permit le Issued,
I shall not employ any person In any manner an as to become subject to the WATER SYSTEM/,TREATING
Workers'Compensation Laws of California. Date PAID
O Z NOTICnt NEW RESIDENTIAL PLMB. SQ.FT. Date Recel t#
Z Z
NOTICETO MPLICANT:$efler making this Certl(late o(Exemptlon,you
H should bemmesubjectiothe Workers'Comperwtlon provisite (the Labor TOTAL:
N Code,you at forthwith comply with such provisions or this perrrdt shall be
9deemed revoked. BUILDING FEE
LU CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there Is a construction lending agency for the performELECTRIC FEB
7 Z arm of the work for which this permit la issued(Sec.3097,Civ,C.) TOTAL
U O Lender',Name PLUMBING FEE
IL I— Lander.Add re,a QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O O l artifythatl havereadthlaapplicatlomand natethatthcabove Inform"no
LU
lacorred.lagreetocomplywlthall cityand ocuntyordloarcesand statelawa PERMITISSUANCE FRES PAID:
} Nrelating to building construction,and hereby authorize representatives of this
H Z city to enter upon the abowmentloned property for Inspection purposes. ALTER OR ADD TO MECH.
V (We)agree to save,Indemnify an d keep harmless the City of CL pectin Date Receipt#
against liabilities, gments,costs, dexpen swhih may In an way.cerm AIR HANDLING UNIT 10,000CFM) SUBTOTAL:
a abut said City sequence f n .M.;.y t AIR HANDLING UNIT(OVER lO,WOCFM) CONSTRUCTION TAX
14
�1
IgnamrcoIAp nt/ContmdorDate EXHAUSTHOOD(W/Duro) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIAL"ISCLOSURE
Willtheappllcant or future building occupant store or handle hazardous HFiATINGUMT(TO100,00011M ��
materlal as defined by the Cupertino Municipal Code,Chapter 932,and the Date Reeel I
Ilealth and Safety Cade Section 25532(a)? HEATING UNIT(OVER 100,000 BTU TOTA ^
❑Yea No
Will the applicant or tore building occupant use equipment or devices VENTILATION PAN NNGLE RESID) ISSUANCE DATE
which emit hasardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP DTI'OR IOO,DM BTU)
Yes No ppqq pp
have read Ileh ous materials reyubenents underChapler6.95 of BOILER-COMP(OVER 100,000 BTU) I1� A D
jus California Ilealth&Safoty Code,Sections 25505,25533 and 2:534.I
understand that if the building does nes comently,have a tenant,that it is my NEW RESIDENTIAL MECH. `'Q'FT MgY19 Q^
992
I-Pon,ibility to ectlly the..part of the requirements which must be at 10y2
be
prior to uanre a a Certificate of Oocuparry.
Owner or authm iced agent CIiYe
Date ISSUED BY.
TO
OFFICE COPY