23728 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Bulldloft Project Identification PEKWT NO.
Building Address: . 2^7 n 8
--lamer one: G lSJ G�T JS
A
a2 CITY OF CUPERTINO-BUILDING DIVISION �r
� C.ntactor'a Na me LIc.No: APPLICATION /PERMIT
IBUR.DINGELEC.TRICALPLUMBINr—MEC LAICAL CATEGORY CONTR LN
Archllect/Engineer. Lie No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address, PERMITISSUANCE � ❑ ❑
BLUG
LICENSED CONTRACTOR'S DECLARATION Ihth bdioflrmthatlam Bcen3ofth. erprovWonsof Cssion.9(commme- APPLIANCESRESIDENTUL JOB DISC ON
Ingweh 1.fullto.andafelon3olthe Buelneeeand ProfesslonaCode,and my
license Is 1.full farce and 1c.If PANELS
LlceneeChss LIC.X
Data ConvectorUP TO 2DOAMPS
ARCHITECTS DECLARATION 201-1000 AMTS
��qq++acX I understand my plans@halt be used as public records. OVERI000AMPS Fr.FLOOR AREA $/SQ.FT.
Fi z�j Licensed Professional SIGNS ELECTRICAL FINA N
6 OWNER-BUILDER DECLARATION SI'ECIALCR2CUIT/MLSC
Z 1-, IherebyafBrmthat lson exempt from the Contractor's License Law for the
c 0 PT 1 rJR
qQQ fallowing reason.(Section 70315,Business and Professions Code:Any city or
F @' county which requbssa permit toconstruct,alter,improve,demolish,ormpalr 741P.METM ORIOLE INSf
< anystmc mpriartoitsieeuamc aborequirestheappliantfos chpermitm
O a U (Ilea signed statement that he I,licensed pursuant to the provisions of the POWER DEVICES
3 -'
0� ConlractoreLicense Law(Chapter9(rommencing with Section 7000).(Divi- SWIMMING POOL ELECTRIC
slon3 of the Bunneea and PrMesslonsCode orthat he b exempitherefromand VALUATION
F S the basis for the alleged exemption. Any violation of Section 7031.5 by any
<
applicant furs permit subjecistheapplicanl to a civil penalty o(not more than OUTLETSSWITCHES.FIXTURES
fiyElundrad
psownolWahepro NEW RESIDENTIAL ELECTR SQ,FT. STORIES TYPECONSTRUCTION
e owner of she property,or my employees with wages cue their @ole
l do
is
c (Sec.744,Busim.hawork+ndthe;Code:rehe Contactor or Licensd for
e La.O Ie(Sec.7044,fluelriess grid Professions Code:The Cantactofe Llcensa law
fie@ oca not apply to an owner of property who builds or improves thereon,and OCC.GROUP RES UNITS
whodoeseuchwarkhim@eB.rlhrough hlsown employees,provided that such
improvemcntsare not Intended oro(fered forsale.If,however,lhebuilding or TOTAL:
Improvement bsold withinoneyearo(compl&l.n,lheownervbullderwill have
itrden of proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOODZDNE ApN
L�I,as owner of the property,am exclusively contracting with Banned
contactors to construct the project(Sm 7041,Business and Professions Code: PFRMITI.SSUANCE
The Contractor's License Law does not apply to an owner of property who
builds or Improves thereon,and who contracts for such p(ojeaa with a ALTER-DRAINk VENT-WATER SIU
cga4actor(s)licensed purmanttothe Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B &P C for this reasonOil
• Owner copyt
Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y
RFC
WORK MAN COMPENSATION DECLARATION Fp(NRFg PER TRAP SCHOOLTAX Y N
[-]I hereby affirm That I have a artl(late of consent to naure,(Sa RECEIPT X
certificate of W.rkea'Compensatloninsurancr ma certified pyhereol(Sec. GAS EA.SYSTEM-1 INCAOUTLETS PARK FEE V N
350q Lab C.)
PcIIry p RECEGAS EA.SYSTEMAVER 4(RA) DING DIVISION
I N
Co�m+any BUILDING DI VISION FEES
I ICertlRed copy Is hereby filed
ed.city GREASEANDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
Dertl(led mpy v filed with the tlty Inspection division.
CERTIFICATE OF O(EMPTION FROM WORKERS' PAID
COMPENSATION INSURANCE Sh.WF.RSA ARYSMRM EA 20UF1' Date Recei tic
(Thlssection need not be completed Rlhe permit It(coon@ hundred dallaa
($100).rless.) HEATER W/VENT/dECTIt ENERGY FEE Y N
I.Aify that[.the perf.ronacr of the work(.,which this permit is blued, Wffitr
I shall not employ any person in any manner m as to become subject to the WATER SYSTEM/TREATING
Workers'Compensad.n lAmof CalBamla.Date PAID
C• Z NOTICETO t .NEW RESIDENTIAL PLMB. SOFT. Date Recei tN
Z O NOTICEcome subject
tothe ftxr Workers
lCo thisCertificateate of Exemption,you
Hshould become subFct to the Workara'Campensallan provisions oflhe Labor TOTAL'
W
Code,you=at forthwith comply with such provisions or this permit shall be
deemed revoked. BUILDING FEE
LU
G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby a/Rrmthat there is a construction lending agency for the perform- - ELECTRIC FEE
C) Z ancrod the work for which this permit is Issued(Sec.3097,Clv.C.)
V O Lender's No. � PLUMBING FEE
LL I- Lender.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1adl(ythatl have madthisapplioHon and stalethattheabove information1 Iscomd.Iagree toc.mplywith all city and county ordinances and elate laws PERMIT ISSUANCE FEES PAID:
co relating tobullding constnrcAon,and herebyaulhorlu representativesofthis
I— Z city to enter upon the abovcmentiu mperty for on purposes. ALTER OR ADDTO MECH. Date Recei t#
(We) ave,in keep her th Cltyo(CupertNo P
agalns Mill pis a , expe Mich ymanywayaccue AIR HANDLING UNIT(TO 10,000CEM) SUBTOTAL'
gaI taidC In ea the gra permit. AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
5 .(App0anl/Cantraci` Date EKHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
YW
HAZARDOUS MATERIALS DISCLOSURE
lllthe applicant or fumrebudding occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCtei [M
material cue defined by the Cupertino Municipal Cade,Chapter 9.12,and the
I lc1alth and Safety Code Section 25532(a)2 HEATING UNIT(OVER 100,000 BTU) TOT?LA
Yea rj No
111 the applicant or ture building occupant use equipment or devices VENTILATION PAN(SINGLE RE'SID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP(3II°OR 100,000 BTU) D
Yee ❑No
have read the bavrcToue malariah requirements under Chapter&95 of BOILER-CAMP(OVER 100,(X10 BTU)
the California Health&Safety Code,Sections 25505,25533 and 25534.1
understand that if the building does not currently have a tenant that it It my NEWRESIDENTIALMECN. 9Q.FT.
responsibility to nctify the occupant of the requirements which must be met
prior to Lssua nor of a Certificate ofOccupa ncy. '(jell UI"`UrC
Owner or authorized agent Data ISSUED BY:
TOTAL:
OFFICE COPY