23399 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification Pld(MITNO.
Building Address: 23399 Jn
nerane. A A A a a 1,641)No CITY OF CUPERTINO-BUILDING DIVISION
Conntr�aRora Name LIc.No: APPLICATION / PERMIT 3//6,6Z
BUILDINGELECTRICAGML BIND-MECHAMCAL CAI'F-('ARY CONIROL�
i a
Archct/Engineer. Lie Na.
QW ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERNETISSUANCE ❑ El 4 El
CONTRACTOR'S DECLARATION
IhthSyionm )o Divsim3 am dheBusiprovisions ndPmfeaons9(e,andm- APPLIANCES-RESIDENTIAL JOB DPSCRETION
inenset Infullforceandefect. theBusinessandProfesNonsCode,andmy C(Al/N� Y✓-q,ffil ��'-
B¢nse m m rail Tara oras effect. PANELS ( f( I I (
Licon lic.N_S— IL'cT/aN J Il.r1 ht I B�
Date Corer x [ tel ljUP TO 200 ANTS
ARCHITECT'S
be
DECLARATION OVEROOAMI'S N
�7 I understand my pore ehaB be used as public records OVER 1000 AMPS Ik I SQ.FT.FLOOR AREA S/SQ,FT.
O
ca �j Licensed Prdeslooal SIGNS ELEC a�o
�<<lr OWNER-BUILDER DECLARATION SPECIALCIRCJ\A R
p., X IhembyafOrm that l am exempt fromthe Contractor's Llmnw law for the
OR , follow ng reason. S lora 7Q lS,Bus nem and Pmfevionn Code:Any tlty or TEMP.MEfTRO LE INST.
Z �qq�yy oountywhkhmqulmaper twrnmtmd,alteglmpmve,deonlbh,ormpalr ^e
'��:aa mystructure primto its issuance,aLsorequfrestheappllcant for such permit to POWPRDEVICE9 DATas
E
d U file a signed statement that he is licensed pursuant to the provisions of the
Contractors License Law(Chapmr9(commencing with Section 7000)of Divi- SWUihRNG POOL ELECTRIC
slon3ofthe B.sIn ,and Prof.m .CW )orthat heisexempttherefmmand J VALUATION
the basis for the alleged exemption. Any violation of Section 70312 by any OUTLETS-SWITCHES-FIXTURES
ra�<S applicant fora permitsubjectnthaapplicanttoacivll penalty ofmt morethan .yt/v
c. Ove hundred delUn(A500). NEW RESIDENTIAL ELECTR SQ.FT. Stt1WFS TYPE CONSTRUCTION
.-�n ❑I,as owner of the pmperty,or my employees with wages as their sole
C7< compensation,wBl d u the work and the structure is not Intended or offered for /
y D
Is(Sec 70K Busimax and Prvfe®IonsCade:TM1e Contractors Li..Law
�$ does not applyjo an owner of property who builds or Improves thereon,and OCC.GROIIP RES.UNITS
who does such work himself orthruugh his own employees,provided that such
Improvements are not Intended mattered forsale.If,however,thebulldingor TOTAL:
Improvementissold within oneycarofeampletion,the owner-buiderwfll have
tl7s�arden of pmving that he did not build or improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
L1 L as owner of the pmperty,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec 7054,Business and ProfessionsCade:
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN&VEM'-WATER(ETV
builds or Improves thereon,and who contracts for such pwjecv with a
cgBV�ctor(s)BLYreadl pursuant to the Contractors License Law, gAIX FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B& P C for this reason
DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y N
Owner Date RFCEB'I N
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y_ N_
I']I hereby affirm that I have a rertiflwte of consent to self-insure,ora RECEBxT a
certiflcateofWorken'Compem imlmura macedified ropythemof(Sec. GAS EA.SY57M-1 INCA OUTLETS PARK FEE Y_ N_
38M,Lab C.) + R[CENT p
Policy It GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
Ce any
r1ccriRed copy is hereby famished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
mcenified copy Is filed with the city Impaction divialon.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200Ff Date RCCeI t#
(This section need nae ba completed lithe permit is foram hundred dollars
(S10fiorless.) WATER BEATER W/VEM/ELCCTR ENERGYFEE Y. N_
I certify chat Lathe performance of the work for which this permit Is issued,
I shall not employ a9y person!nary,ma asA, eron subject to the WATER SYSTEM/TREATING
workerst , yj Lpn laQ+ae(l;alito Qam . PAID
C• Z Applicant AN (6.wn , � Vi t +Pti .� NEWRESIDENIUL"ll. SQFT. Date Recel [#
Z O NOHCET Iject to.l—�er dgthis pensation preo(Exempti.the Labor
� N should become subject to the Worker'Compensatim provisions of the Labor TOTAL:
cCode,you must forthwith comply with such pawtsions or this permit shall be BUILDING
W _ deemed revoked.CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL C Ihereby affirm that there is a construction lending agency for the perform TOTAL: ELECTRIC FEE
7 Z once of the work for which this perrrdt is Issued(Sec.3097,Civ.C.) PLUMBING FEE.
O 2 Mder'n Name -
LL F 1.oder+Addmas QTY. MECHANICAL PERMIT FEE MECHANICAL PEE
O W (certify that have read thisappBotionand atatethat theabove information
bcorrect.I agree to comply with all cityand county ordinances and state laws PERMIT LSSUANCE FEES PAID:.
} W relating to building construction,and hereby authorlu representatives ofthis
F Z city to enter upon the above me t1or,M property for inspection purposes. ALTFRORADDTOMECH. Date Receipt#
V _ (We)agree to save,Indemnify an d keep harmless the City of Cupertino AIR HANDLING UNIT(TO 10,000 CFM)
I
gamstliabilities,pdgme mn.andexp ses whlchmaylnanywayacaue SUBTOTAL:
agalnsty ;once an of the gr ting of this pe I/ �/
AIR HA NDLING UNIT(OVER I O,ODD CFM7 CONSTRUCTIONTAX
Slgmty Appllcmt Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAIR RDOUS MATERIALS DISCLOSURE
Will the a pplicant or future building occupant store or hand to haramms HEATING UNIT(TO 100,WO BTU) Date Reuel t#
materlal as defined by the Cu pertlno Murdcipa l Code,Chapter 9.1 Z and the I
—
i-Icalth a rad Safety eode"ctlan 25532(x)7 BEATING UNIT(OVER 100,000 BTU) - - TOTAL: V ll
❑Yes I OfI No
Willtheappfiaa furore building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) °.7 ISSUANCE DATE
p which emit harardom air cont,minantsas defined by the Bay Area Air
Qu a lity Management Dist ct7 BOILER-COMP OHP OR 100,000 BTU)
No
4hYes acmad the F ousmaterials rqulremnntsunderChapter6.95of OER-COMP(OVER IOO,000BTU)
(the California Health&Safety Code,Sections 25505,25533 and 25534.I
'understand that if the building docs not currently have a tenant,that it is my NEW RESIDENTIAL MECH SQ.F7 T
responsibilityto notify th occupant of thi requirements which must be met P A O O
priorto.0wayn✓n'ra ate opar .
ibL ccu ry
r r
DWn11 aultttttt g Date TOTAL: ISSLTTBY:
IfV .
OFFICE COPY LUr�fl,„rte