23676 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES'— USE BALL POINT PEN ONLY
Building I'm'ect identification PERMIT NO.
Building Ads:
23676
arae: one:
wne„e CITY OF CUPERTINO-BUILDING DIVISION
Cont. '.Nares / uc.Nn APPLICATION / PERMIT
V BUILDING-ELECTRICALPLUMBING- E HANICAL CATEGORY- CONTROL N
Archimet/Engineer. Lie.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address PETIITISSUANCE ❑ ❑ _ ❑
LICENSED CONTRACTOR'S DECLARATION
Iherebyafftrmtbatlamlicensedunderp.Wonsgf Chapter9(commenc APPLIANCMRESIDENTIAL JOB DESCRTFr10N
ingwith Section 7000)of DlvlaIor3ofthe BuaincssandProfessi...Code,andmy
license Is In full force and effect. PANELS
License CU. Lie.a - UP � � �Qa(/e�/'•�
Date Contractor 201-1000 AMPS
ARCHITECTSDECLARATION OVER1000AMPS SQ.Fr.FLOOR AREA $/SQ.Err.
0O OC Iundentand my plans shall be used republic rerorda
k (). Licensed Professional ISICNS ELECTRICAL
<6 w OWNER-BUILDER DECLARATION
IhembyaffimIn �n SPECIAL CIRCUIT/MI5C
owingracuen. edum731S,Elfromthe Cgntractorb License lawfm the -
O Z F (ogowm aeon.(Section 70315,Business and Pro(dssbns Code:An ct -- L :• q
countywhich requlma permit tocorestruat,alter,Improve,derrnlbh,orrepair 7FMP.MEf�RORPOLE INST
anysvucture poor to Its Issuance,also requires the a ppBcant for such permit to POWER DEVICFS �� 0 –� I� [ '
W6 i1 file a signed statement that he b licensed pursuant to the provisions of the �' J �r. 'i
04 Contractor's License Law with Section 7")of Divi- l VALUATION
G SWTMMINC POOL ELECTRIC,
30 the
base i foBwinessand ProfenioruC nyviothaheb exam therefrom and
the Raab for the alleged exemption. Any violation of nactk a 7031.5 by any �–
<5 OUTLETS-SWITCHES
applicant for delta.
applicant to a dill penalty of not more thin
c. �� flue hundred dollar($500). NEWRFSIDENTIALELECTR SQFr. sTowiS c TYPE CONSTRUCTION
�n ❑I,as owner of the property,or my employees with wages as their sok
E7< m
e(Se
compensation,will clothe work.and thestctum 6 not Intended or offered for
NO sale, 7064 Business and Profealora Code:The Contractors License Taw s
p $ docs not apply to an owner of property who Wilds or improves therroR and
'S^ who does such work himself or through hisown employees,provided that such OCC.GROW RIS.UNITS
Improvements are not Intended oroffered formic.If,however,the buildingor - TOTAL:
Improvement bsold whhinoneyearofcompIMWmtheowner-bullderwill have
tl(q-Ixlyden of proving that he did not build or improve for purpose ofsale.)., QTY. PLUMBING PERMIT FEE FTADD ZONE x APN
LJ L as owner of the property,am exclusively contracting with Heeded PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code: 1pl a++ • "
The Contractors License Law don not apply to an ownerof property who
Wild.or Improv.thereon, and who contact•for such pmjem with a ALTER-DRAIN&VENT-WATER BTA)
. I cmr(s)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B&P C for this reasonOUISJDE FEES
' DRAINS FLOOR ROOF,AREA,COND. SANITARY . Y_ N_
Owner Date RECEB'T p
WORKAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOL TAX Y_ N
ffi _
❑I hereM
by arm certificate I have a te of consent to uln
14sure,or RECEIVE X
mnifiateof Worken'Comper timlmmnmoracAlfledmpythenrof(Sec. GAS FA.SYSTEE7-I WCOUTLEIS PARK FEE Y N
3800.1abCJ �. 3 O. 2 —
RFCEI X
Poky Y CAS EA.SYSTEM-OVER 4(FA) BUILDING DI VISION FE IS
_ _ Com any
LCertified–copy U hre urns ed' GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
ertBied copy is,filed with the city inspection division. r
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE THAI' PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Recei tq
(rNssenlon need na be completed B the permit b(glom hundred dollars
(SIW)or Ica.) - WATER I-[FATEft w/� ./ELfOTR ENERGY FEE Y_ N_
I certify that In the performance of the work for which this permit is brad,
1 shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING a
Workers'Compenatlon Lawsof California.Date PAID
O Z Apphant NEW RE9D IJT AL PLMB. SQ}T. Date RCcei t#
Z O NOUCETO APPLICANT.If,after making this CenNateof Exemption,you
should become subject to the Walken'Comperaatlon proal iom of the Labor TOTAL:
W Code,you most forthwith comply with such provlslora orthU permit shall be BUILDING
deemed revoked.
LLL >CL _
G CONSTRUCTION LENDING AGENCY SEISMIC PEE
I hereby affirm that there b a conatructlon lending agency for the performTOTAL: �t ELECTRIC FEE
7 Z anwoflheworkforwhichnhbperm isimed(Sec.3(197,CIv.C.) PLUMB[NCFEE
LL O LctuLe.der.Name - TY, MECHANICAL PERMIT FEE
14, 0 b<naeriAaarea Q MECHANICAL FEE
OW Imot.I agree to comply with
allcitlandcountyordinances
rdinancs and
S blatingt.building complywith alndtyandrouby horice inanmsand state PERMIT ISSUANCE FEES PAID:
} reytoenobuilding t romovelnutioned property or inspection
o(thb
F Z citytoto ave,he indemnify aned property for late Cit purposes. ALTER ORADDTO MECH.
? (We)agree to ave,Indemnify an d keep harmless the City of a pertun,accom Date ReOTAL
V agai IlabilBles,pdgmenb,ros.and expense which may In any wayaav„e AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
ag rest id City in co nm of the Ranting of this Pe t.
AIRHANDL1NG UNIT(OVER IB0BaCFM) CONSTRUCTION TAX
SI tura of Applicant/ ontracmr Date EXHAUST HOOD(W/DUCT) CON$TRUCTION•TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE `
Will the applicant or future building occupant store or handle haeardous HEATING UNIT(10 100,000 BTU) Date ReceI tis
material as defined by the Cupertino Municipal Code,Chapter 9.l;and the -
I1e.Ithand Safety Corse,$eclion25532(A)7, t HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yn }(�(ni No
WIIl the applkanto vrd building omspant use equipment ordevices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit havrdous air contaminants as defined by the Bay Area Ain
Quality Management District? : BOILER-COMP OHP OR 100,000 BTU) _ P N
p
n t
YNo
Ihavereadthe hausmaterials requirementsunder Chapter 6.95of BOILER-COMP(OVER 100,000 BTU)
the Ca Illinois Health&Safety Cod,Sealoma 25505,25533 and 25534.1 6 1992
understand that if the building does not currently have a tenant,that It b my NEW RESIDENTIAL MECH. SQ.rr fl1tl�
respomibilitylonotify the occupant of the requirements which must be met AUG .
Prl lssuancd Ma Ce Iflat to parry.
7-o2yy CII" .'11114V
cr or authonud agent– Date ISSUEDBY:�•
TOTAL:
OFFICE COPY o'