23277 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Preis t Identification PERMIT NO.
Bolding Address:
23277
Gj
name ante: one:
_ CITY OF CUPERTINO-BUILDING DIVISION
Cjo Name: Lie,No: Q APPLICATION / PERMITAIIIM 4,Z.
/ BUTLDINGELFCTRICALHUMBINC-MECHANICAL CATEGORY CONTROL#
Itect/Engineer. Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. PERMITISSUANCE f-l/ ❑ 1:1 1:1LICENSED CONTRACTOR'S DECLARATION l}�
I hereby affirm n7000'hat fDivl.ce3.fthOed uai.iaions.d Pro Cha.r.0 .,and
APPLIANCES-RESIDENTIAL JOB DCSCRIPITON
ing with me.I Sect1on7000)of Dlvfect' ofthe Buslneasand Pro(eulonsCode,and my
i.1mose In fol effect. PANELS
Dat Clan We/ �q,�q�yyjd-/q_�- ,.,.
Dat Contra-� 3 FMR A ' �CY/
AR shall O. ATIO 201'1000 AMPS
Ore pZ ]undentend my plan shall be used upublic records. OVER 1000 AMPS SQ.Fr.FLOOR AREA S/SQ.FL
Fl Licensed PmNesstaral SIGNS ELECTRICAL
<< OWNER-BUILDER DECLARATION
1r. SPECIAL CIRCUIT/MISC
z Ihereby a(Rrmthal l am exempt fromthe Contractors License Law for the
following emaon.(Section 7031.5,Business and Professions Code:An city or p
O '"� Y ty TEMP.MEI7R OR POLE INST. IJ
cauntywhmprlrtoia ance,momqul lter,lmphcantfrrelehper ttlr
g'O any structure statement
Issuance,licensed
pursuant t the provisions
of
a POWER DEVICES / N1 I . ;a
file a signed etatenent that he b Ilaneed punuut to the preNsbv of the L.
u. Contnnore Llceve Low(Chapler9(mmmencingwlth Smion7000)of Dlvl- VALVA O
H30J sloe 3 ofthe Bualnesa"d Pralesslov Code)orthal he beumpt tlerefromand SWIMMING POOL ELECTRIC #off
O.•77 the basis for the alleged exemption. Any violation of Section 70315 by any OUTLFTSSWITCHFSFIX ORFS DA
applicant fora permit subjects the applicant to a civil penalty of ns more than
five hundred dollen($500), NEW RESIDENTIAL ELECTR so.
'
�n ❑I,as owner of the properly,or my employees with wages as their sole S TYPE C014SISUCTION
compensation,wll do the work and the structure is not Intended or offered for
Osale ISM 7041,Business and Pro(eeabv Code:The Contmdoes License law
t{ 'B does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP RES.UNITS who docs such work Mmnlforthrough his own employees,provided that such
Improvements are not Intended or offered for sale.If,however,the building or TOTAL:
Improvement b sold within one yearo(complelloN the owner-bullderwill have
t rden of proving that he did not bund or Improve for purpose ofsalcJ. QTY. PLUMBING PERMIT FEE
L as owner of the property,am exclusively m ctncting with licensed HOOD ZONE MN
contractors,to construct the project(See 7044,B..m.and Pmfmkms Code: PERMTTI.SSUANCE
The Contractor's License Taw does not apply to an owner of property who ALTER-DRAIN k VENT•WATER(FA)
balR
da or Improves thereon, and who contract. for such pRojes with s
egR((agor(a)licensed pursuant to the Contradm'B License Law. BACK FLOWP T FEE SUMMARY
IJ I am exempt under Sec B k P C for this reason
DRAINS FLOG P,' A Y Y N
.Owner Date RECEIPT N
r-�y! WORKMAN COMPENSATION DECLARATION FIXTURES PER SCI100L fAX Y N
•'�1_II hereby affirm that I have a certificate of consent to self-Ineun,ora RFGEIPT N
mrtifimteof Worken'Compomatlonlvunnmora.Alfiedcopythereof(Sec. GAS FA STEM1 T�{TTL A Y N
3800,
q Yb CJ LJG/�/�747.3 RECEIPT M
Cram anv n/ Py CAS EA. t4(EA) BUILDING DIVISION FEES
Qy,etllfied copy is herebyfurnished.the city CREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
QjeelliBed ropy V tiled with lM city impaction division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER- STORM EA 200Ff Date Recei t#
(Thlssemna need not be completed lithe permit is fur one hundred dollar.
(51I0)urWATER HEATER W/VRNT/ELECTR ENERGYFEE Y N
Icedify fy that in the performance bbw
oance of the work for which this permited,
Ishall not employ any person In any manner an as to become abject to IM WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID
OZ APpllcant NEW RESIDENTIAL PLMB. SQ3T. Date Recel tic
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
t" should became subject to the Workers'Compensation provlelom ofthe Labor TOTAL,
fA Codgyou..I forthwith comply withsuch provialoramthb permitehallbe ssas�
W > deemed rooked. UI r
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d a Ihembyaffirmthat there b a construction lending agency for the perform ELECTRIC FEE
M Z arca ofthe workfur which this permit is Issued(Sec.3097,Civ.C.) TOTAL:
U O lenders Name PLUMBING FEE
LL t- Lender'.Addreas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icerti(ythml have read this applicatlonand datethal lheaboveinformation
6 bmrrect.I agreeto comply with al city and county ordinances and slate laws PERMIT ISSUANCE FEES PAID:
relating lobullding construction,and hereby authorlm representatives ofthis
F mcity to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH.
Z (We)agree to save,Inderdfy an d keep harmless the City of Coped Ino —Date RCCeI Ptil
agasat liabilities,judgments,mss and expenm which nay In any way accrue AIR ITA LADLING UNIT ITO 10,000 CFM) SUBTOTAL:
aga lvt old City in comae quer of the granting of this permit.
AIR IiANDWNG UNIT(OVER IO,000CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future bu tiding occupant stare or hand le hazatdom HEATING UNIT(TO 100,000 BTU) Date RerciptIt
material as dell red by the Cupertino Mu riclpal Code,Chapter 9.1 2,and the
Health and Safety Cade,Sclift 25532(a)T HEATING UNIT(OVER IDB000 BTU) TO
Yu ( No
Wlilthe applicant or ture binding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air mnt manta as defined by the Bay Area Air
Qua ity Management t BOILER-COMP OFT OR 100,000 BTU)
Yds No 9
4e read the hazy ossa rvterials requlrcmens under Chapter 6.95 of BOILER COMP(OVER 100,00)BM
•The Califomla Health k Safetybuilding
Code,Sections25505,25533have
a tend,that I.rdera � � ��
respor a tl(the bulld ccupara not emqu currently hick that It met NEW RESI DEN77AL hf[iCli._SQ.1-7 C•
prior duanllity si(Cthe ocavpantof p.ocy, lrenenta which must be net a
prior rssuan Cc Icate o(Occupanry,
�(O L
Ow or uthorl age Data
TOTAL: ISSUED BY:
OFFICE COPY ,