23047APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification-
PERMITNO.
Building Address:
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.. 23047_
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CITYOPCUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
A A
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CATEGORY
CONTROL N
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BU LDINGELERC CAL UMBING-MECHANICAL
Architect/Engineer.
lL
QTY' ELECTRICPERMIT FEE
BUILDING PERMIT INFO
PERMITISSUANCE
Address:
❑ ❑ ❑ �I)
LICENSED CONTRACTOR'S DECLARATION
Ihambyaftbm that l am lkensed under provisions of Chapter9 (memencre,
Ing with SetH 7000)of Wslon�flhe u essand['m(nslonsCode, and my
APPLIANCESRESIDENTIAL
JOB DESCRIPTION
license is In 1 effect. I'llLl/IJ—
PANELS
License la Ic.p
c -s/'1„ a„�_- -_ —
Dat Cle for
r UV�A�JaF4aR�'sT/ti._.
201-IODDAMPS
ARCHITECT CLA To
I un ens my plats ehaB be used as public records.
OVER IOW AMPS
SQ. FT. FLOOR AREA
SIGNSELECTRICAL
Licensed Professional
SPECIALCIRCUIT/MISC
OWNER -BUILDER DECLARATION
Iherebya(fimnthatI am exempt from the Contractor's License Law for the
following reaeon.(Scdion 70315, Busmeseand Professt... Code: Any city or
countywhlchrequi aper ttommh ct,altegimpmve,demolbh,or Mpair
�')n � f�• � 9
-
'
pp
TEMP. METER OR POLE INST. — B I
anystructure priorto Its fine ance,alsorequinsthe applicant forsuch permit to
file a signed statement that he Is licensed pursuant to the provisions of the��
Contractors License Law (Chapter 9 (commencing with Section 7000)of Diel-
sion3 of the Business and Professlow Code)arthat heIsexempt lhere(romand
the basis for the alleged exemption. Any violation of Saction 70315 by any
applicant for a permit subjects the a pplicant to a civil pemltya not mon than
POWER DEVICES
E F
SWIMh17NG POOL ELE C �"
OUT1ATSSWTTCHEyKXTURFS
NEW RFSID ELECTR SQ.FT;
live hundred1, asoowndoler of the pN.
O 1, as owner the property, or employees with wages m thele sale
STORIES
TYPE CONSTRUCTION
,
mmponv0on, I do he Intended or offered for
weak, and thesCde;
he Contactorct
vie (Sec. Code: The Llense law
Business and License
Business
,
apply f property or Impewes
empIrimprwt stand
whodcdoes tapplytoan owner ofpropedywho builds
who hIsown e ; lhatsuch
hlmsended
OCC,GRON'
RIS. I1Nff5
orough
improvementsarenot Intended . If, lm ctheprovided
scom am not or
TOTAL:
earofoo plefio.ILhower-b deer illhading
improvement within n,theowner-
umpor fi
proving he did net buildnforeve for rposeew0 le.).
tFLj Lanof wner of thephedldna exclusively =trading Timm.
ess and I'm with lirenxd
u I, os owner of the property, am.7044, Business Code
centaamsct construct the project (Se. Bus Nem and
QTy, PLUMBING PERMIT FEE
FLOOD "LANE
APN
IT ISSUANCE
a property
The Contractors License law does cot apply m an owner a property who
apply
o centrads ice se La (opcts with a
Wilds or Improves thereon, to the
c l are exempt under anuothe Contrador'e License Law.
LJ I am exempt under Sec e & P C for this reason
ALTER -DRAIN & VENT- WATER (EA)
-
FEE SUMMARY
BACK FLOW PROTECT. DEVICE ''-
OUTSIDE FEES
DRAINS FLOOR ROOF, AREA, COND
SANITARY Y N
ftECEPT0
Owner Date
WORKMANCO Mu'DECLARATION
I hereby affirm that I have a certificate of consent to xtf-hos e, ora
kcopythermf5ce.
cerfifi.eofWorkers Com erwtlon reurancemaamfd
Mile, Iib C.)/jP�� 1 �J-
FIX.NRES PER TRM
SCI{OOL TAX Y_ N_
RpCpR.p #
GAS EA.SYSTFM-11NC4 815
PARK FEi Y_ N_
Policy# IINs-Gs^ar /
once any__
GAS -EA, SYSTEM -O 4(EA)
RUILRECEIPD1VI510N Fi:Eg
LCertlfled cepybOureetyfurNsmd.,
-f�nIOed copy is filed with the city impaction division.
GREASE/INDU L WASTE INTERCEPTOR
PLANCHECK FEE
GREASE
CERTIFICATE. OF EXEMPTION FROM WORKERS'
PAID
SEWER- NITARY-STORM EA. 200FT.
COMPENSATIONINSURANCE
(Phis section need not W completed 8the permit Is for one hundred dollars
Date Remi t#
�HEATTRW/VENT/ELECTR
ENERGY FEE Y_ N_
($100) or lose.) �
I comfy that U the performance of the work forwhlch this permit Is Issued,
WATE{SYS.IEM/TREATING
1 shall not employ any person in any manner sa as to become subject to the
Workers Compensation Laws of California. Date
PAID-
AIDApplicant
NEWRESIDENTIALPLMB. SQJTr.
Applicant
Date Recei t#
NOTICE TO APPLICANT: IL after making thisCompute of Exemption, you
should become, subject to the Worked Compensation provisiom of the Labor
TOTAL:
.BUI IN
Code, you mut forthwith comply with such provbiom or this permit shall be
demand revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I herebyafOrmthat there is a construction lcedingagenry, forthe perform.
ance of the work for which thb permit e, Issued (Sec. 3097, Civ. C.)
Lender's Na mn
Lenders Address
I mdIlythat I have readthb application and statethatthe above Information
iscorred. l agree to comply with all city and county ordimeem.nd Asia laws
TOTAL:
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICALFEE
PERMUISSUANCE -
FEES PAID:
Mm bull ngcemtructlon, and hereby authotlx representatives of this
city to enter .the above-mentkned property for inspection pu rposes.
(We) e e vvq Indemnify an d keep harmless the City of Cupertino
,
ALTER OR ADD TO MFCH.
Date Receipt#
AIR HANDLI NG UNIT (TO 10,000 CFM).
SUBTOTAL:
aga1v111 IRt mane,"..ad expenses which may in any way acme
against dC n granting athlape It.
AIR HANDLING UNIT (OVER 10,000CF.M)
CONSTRUCTION TAX
Slgrmmreof Ap eam
B/Contrador Data
EXIwusTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
' HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or metre building occupant store or handle hazardous
HEATING UNIT(TO 100,000 BM
Date 'Recel t#
material as defined by the Cupertino Municipal Code, Chapter 9.1 2, and the
Etralth and Safety Codecc�Section 25532(a)?
F-1Yea u No I-
-
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
Willtheapplicantorfmumbuildingocmpantuseequipmentordevices
Which emit baraedous it centamimnts as defined by the Bay Area Air
Quality Management District?
YesI�No
BOILER -COMP OHPOR 100,000 BTU)
BOILER-COMP(OVER I 00,000 BTU)
Thaveread the h.2usmaterials requlrementsunder Chapter 6.95of
PAID
the California Health & Safety Code, Settlors 25505,25S33 and 25534. I
understand that if the building does not mreently have a tenant, that It Is my
NEW RL9IDENTIAL MECH. SQ.FT
responsibility m notify the occupant of the requirements which =at be met
prior to Issuance a a Certificate of Ompancy.
sy
FEB I 19��
ISSUEDBY:r r ' I IIIIYU
Owner or authorised agent - - Data
TOTAL:
OFFICE COPY