23701 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
B.IMI.g Yra'nct Identification PERMITNO.
BuildinBoo
�r ►U ) ofl l '/Uc7 1 23701
v ea APPLRSVff0R3I1R9IrrAT=
CITY OF CUPERTINO-BUILDING DIVISION
cant nor'aName: Tic.No: APPLICATION / PERMIT
BUILDING-ELECTRTCAUPLUMBING-MECHANICAL CATEGORY CONTROL a
Arch teat/Englver. Lk.Nre
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. PERMTISSUANCE �L ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION L�1
I hereby Um0)odDmBcen3ofthe under
usiBmsand Pet Csions odeanene APPLIANCESRESIDENI7AL JOB DPSCRnrI']ON
In is enfall to.and effe on3ofthe Buslneuand Pte/caUonsCade,and my
LI.Blicense la in fun tura and c.N PANELS
Date Claes Lontr2DO Lt)1\
Date GHITECr 11.-7\'p/l!/1
ARCHITECTS DECLARATION OVE000AMIS
�Z I understand my plans shall be used n public reams OVER 1000 AMPS SQ.FT.FLOOR AREA $/ FT.
CO
(/ Licensed Professional SIGNS ELECTRICAL
Q OWNER-BUILDER DECLARATION
Yn SPECIALCIRCUIT/MLSC
owing rafffirentifiatl sna.fection cxemptfromthe Centraneraicena lawf.the
following reason.Genion 70313,Business and Professions Code:Any city or
TEMP.METER ORPOLE INST.
county anystmwhich
mpr orlresa oltsis anceaiomquimit toconstract, stheapituntfrsuchper ttlr
any stmamre tatemente that
he Is alcensed pursuant
to the
provisions
ofNt a POWER DEVICES
IIIc a signed statement that M b licensed pursuant to the provblov of the
30�a eon3ofthe BuLicense
eineu and PrdespsalevCodne ort�ghei�M1 SeRiantFerefmm�nd SWP/MING POOL ELE C VALUrA,TIO�
Q 5 the basis for the alleged exemption. Any violation of Sections 7031.5 by any OUTLET&SWITCHFSF1
g appbmntforapermitsubja theappRl.ttoadvllpemltydnnmoa than ✓
$ five hundred delta.(ISM. NEW RESIDENTIAL ELECTR
❑I,as owner of the property, STORIES TYPE CONSRLUCTION
p perty,or my employees with wage as there dole
CZn compensation,70K will do Bu.inetheworkandtheatructure,Is c:The ot Contractor.ordfneLaw for
9a P O dale(Sec.apply
to amen dna f pmpe ty Cade The C improves License Law
L]S$ does notapply torn owner otp rough who
nemorlmproovide thatecon,and OCC.GROUP RES.UMTS
who
ovdoes
mentsa norinelfor edoroffe dis owneme.If,how, er,theuildisuch
Improvementsamintendneyearfcmpro-a Mthh ner-buOderitdfngee 7 A
improvement pros within he didawo it porimpmveforpurp0 cofsahave
try�aben ofprovingof teperforty,a b exclusively
osth licensed
QTY. PLUMBING PERMIT E FLOODZDDIE APN
Gtr L os owner tr the property,(S a 0K Business
contress and pro with is Code: PERMIT ISSUANCE
The Co.s to avimct thew doe(Sec apply
Busmen and Rdcnlov Code:
The Contnnoro e. thereon,
law don not apply tct an owner d property who ALTER-DRAIN 6:VENT-WATER(EA)
Wild. or Improves thereon, and who contracts ice seeL p(ojMe with a FEE SUMMARY
<ff, ornr(s)
exempt
under ant to the Contractor's Llrnnce Law. gpCj(HpW PROTECT.DEVICE
IJ 1 am evempt under See B&P C for this rescan
OwnerDate DRAINS FLOOR ROOF,AREA,COND. SANITARY _ RFGQI7R
WORMAN COMPENSATION DECLARATION FD(7LRES PER TRAP SCHOOLTAX Y N—
❑I hereK
by a/firm Ma
that I have a rtinata te
of consent to stir-insure,or a RECETT a
anlflcate ofWoAxsei Comperuationlvuranc as certified ropythereo/(Sec. GAS EA.SYSTEM-1 LICA OUTLETS PARK FEE Y N
3800,Lab C.)
Policy R RECEIPT N
GAS EA.SYSTEM.OVER d(EA)
Com any BUILDING DI VISION FEES
❑pCenified copy s hereby famished. GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
❑Certnied copy in filed with the city ivpectlan division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATIONINSURANC[ SEWER-SANTTARY-STORM EA.300FT. Date Recel t#
(Fhiaeetlfon need not be completed if the permit is for one hundred dollars
($100)or1cs.) WATER HEATER W/VENT/ELECIR ENERGY FEE Y_ N_
I m tify that In the performance of the work forwhich this permit is issued,
1 shall not employ any person In any manner so n to become subjectto the WATER SYSTEM/TREATING
Workcri m
Copensation wa
Laof Callfomla.Date PAID
O Appnant Date Recd t#
2 NEWRESIDENTIALPLMB. SQFT.
Z O Nould bcOAPPUCANT:R,afterers'Co thin Certificated Exemption,You
Code, be ams subjectto the ply with
Comprovisinprovfgovofthe Labor TOTAL:
LU N dremodr rwei forthwith comply with such provisions or ihb permit shall be BUILDING EE
W domed revoked. 4
CONSTRUCTION LENDING AGENCY SEISMIC FEE
tl Ihercbyaffirm that there bamvwctlon lendingagenay forth.perform- TOTAL: ELECTRIC FEE
0 Z anceaftheworkforwhich this permit is issued(Sec.3097,CIv.C.)
U O Lender.Name PLUMBING FEE
LL F- Lender's Address qN. MECHANICAL PERMIT FEE
O W Icertifythml havercaaihbappllcatfonand a ittethAtheaboveinformation MECHANICAL FEE
a bmrmn.Iagneetocomplywith allcityand countyordlnanmand statelaws PERMFFLSSUANCE FEES PAID:
>. W relating tobulldingmvtrucdon,and herebyauthorlze representatives ofthls
tl to entero n the abovecramaloned propertyfor W Ion ses. ALTpt ORADDTOMECH.
~ z city
agree to save,Indemnify an a ehaNen the City of cu pert too Date Receipt#
V
against liabilities,' d .,oars a od ex sea which may In a AIR HANDLING UNIT 10,000 CFM)
❑ g.en pen r 9y�Kar SUBTOTAL:
agai teal CR In conaequ he antingdthlep n •fJ. �r�
a/I. 1ANDWNG OMIT(OVFJt 10,000CIM) CONSTRUCTION TAX
igr tf Appllant/Contractor to EXRAUSTHOOD(W/DUC) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Bit a applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recel t#
But mil a defined by the Cupertino Municipal Code,Chapter 9.17,and the ---
Ilea fid Satety Code Section 7S537(a)9 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes r!No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Arca Air
Quality Management District? BOILER-COMP O)D'OR 100.000 BTU)
[? Yea No fid '
hreadthchavrdOus materials Sections
25555533 and 255r5.95 of BOILPR-CON,P(OVER 100,000 BTU)
a she understand
at lithk afetybuilding
Code,Senbnently have a t and,that I
understand that lithehfy the occupant
not a currentlyhavetenant,slut It mcit NEW RESIDENTIAL MIiCH. '(7.IT MAY2 S
responsibility to issityto of a notify ocamfOcuixt rcquircmenta which must be met
prior to Lssuana d a Certificate of Oavpancy.
CITY f)
Owner or authorial agent Date ISSUED't'te r .�
TOTAL:
OFFICE COPY