23527APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
PERMIT NO.
Building Address:
zt e �co �S7fi 7 J= �
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23527
one:
A A
CITY
OF CUPERTINO- BUILDING DIVISION
APPLICATION if PERMIT
� � � asz-
contra o .mama: Lic.N.
BUILDINGELECTRICALML BINGMECHAMCAL
CATEGORY
CONTROL#
ArchitM /agim er. Lic. No,
QTY
ELECFRICPERMIT
FEE
BUILDING PERMIT INFO
Add..
PtRh17T ISSUANCE
1:1 E] 1:1
LICENSED CONTRACTOR'S DECLARATION
I hereby that l licensed Cssions9de,and c
APPLIANCESRFSIDENr1Al
JOB DFSC ON
PANFTS
ectIonrm
ingwith 7000) ofd affect. the Businessand PmfesgonsCode, and my
license Is In bill force and effect.
License Class
n �� L` 0c—
/l.Y_
Date GOmtntOr
Cortr
UP TO 2DOAM25
701 -1000 AMPS
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
OVER 1000 AMT'S
SQ. Fr. FLOOR AREA
s /SQ. FT.
SIGNS ELECTRICAL
Licensed Professlonil
OWNER - BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following quimsaper Business Propm , e=le hnydtyor
awntywhlch toss permlero provgdertnit.h,or rcpilr
D
y�
B T {._ R
U Y L.
SPECIAL CIRCUIT /MISC
TEMP. METER OR POLEINST.
any ahuturc tatema ft. that he is alsore d purut to the for such
riot alsore requires the applicant
ona, of permit e
Die i signed patemeLa that ha is licensed pursuant it the proviiloro of the
Cora ofthe LlceveandPronegos(mm)orthag wlthxMbn7erafra and
slon3 Dinh. Businessland ProfmlonuCode) orthg he is exempt thercfromand
POWER DEVICES
/a1
ykz
LON
SWIMMING POOL ELECTRIC
DATE
the bast. for the alleged exemption. Any violation of Section 70315 by any
appBmnt for a permit subjects the applicant to a civil penalty of not more than
OUTLETSSWITCHFSFTXILRFS -
Ova. hundred dollars (S.M.
❑ I, as owner of rho property, or my employees with wages as their sole
NEWRESIDENTIALELIECTR �Ff.
STORIES TYPE CONSTRUCTION
'
compensation, will do the work, and the structure Is not intended or offered for
sale l5ee 7014, Buguss and Professions Code: The Contractor. License Law
does not apply to an owner of property who Wilds or improves Ihareon, and
who doessuchwork himselforthugh hlsownempleyess , provided that such
m
OCC.GAOU!' AFS.IJNRS
TOTAL:
Improvements arc not Intended oroRered forsale. I(howevep thebuilding or
Improvement t. sold within oneyearofcompltion, the owner - Wilder will have
t nofpmvIng that ha did not hued of improve tar purpose or,ak. >.
ow r of the property, am exdunively contracting with Ilcenaed
tnton to rovtruct the project (Sec. 7044, Bu.ineas and Iarofesslaru Code:
QTY.
PLUMBING PERMIT
FEE
FLOOD ZONE APN
PERMIT ISSUANCE
Contntor'e Llcenx law dcea not apply to an owner of property who
Wilds or improves thereon, and who contracts for such projects with a
cl5 actor(.) hcenmd pursuant to the Contractor's License Law,
LJ I am exempt under Sec. B & P C for this reawn
ALTER -DRAIN &VENT- WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE FLES
DRAINS. FLOOR ROOF, AREA, COND.
FIXTURES PER TRAP
SANITARY Y N_
RFCEB p
Owner Data
WORKMAN COMPENSATION DECLARATION
QI hereby affirm that 1 have a certificate of consent to self-insure, or a
certl0cate of Worker Compeuation Insurance or a certified copy thereof (Sec.
3800, Lab CJ
SCHOOLTAK Y N
RECEEPT X
GAS EA. SYSTEM -1 WC.40UlLEIS
PARK FEE Y N
RECEB'T p
Policy X
Coco any
GAS EA. SYSTEM -OVFR 4 MA)
BUILDING DIVISION FEES
Certified copy III hereby furnished.
�Certlfied ropy Is filed with the city inspection division.
CREASE /INDU57RL WASTE INTQiCEPTOR
PLANCHECKFEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
SEWER-SANITARY-STORM FA. 700F7.
COMPENSATION INSURANCE
(Thissection need not becompited 1fthe per it t.foronehundreddollars
Date RCtt`I t#
WATER HEATER W /NEAP /FLFCTR
ENERGY FEE Y_ N_
(s1(C)orleas.)
I cortifythal in the performance of the work forwhich this permit Is lassoed,
WATER SYSTEM /TREATING
I shall not employ any person in any manner x as to become subject to the
Workers' Compensation laws of California. Date
PAID
NEW RESIDENTIALPLMB. SQFr.
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should Wcoma subFe to the Worker' Compensation provisiom of the Labor
Date Recei t#
TOTAL:
BUILDING FEE
Code, you must forthwith comply with such provisions or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I hereby affirm that there Is a construction lending agency for the perform
ELECTRIC FEE
ance of the work for which thin permit is issued (Sec. 3097, C1v.CJ
Tender's Name
Lender's Addma.
1 certify that I have read this application and state that the above information
Is cormd. l agree to comply with all city and county ordinances and gate laws
PLUMBING FEE
QTY,
MECHANICAL PERMIT
FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating to building construction, and hareby author) s representatives of this
city to enter upo above - mentioned property for inspection purposes.
(We) agree u m indemnify n d keep harmless the City of Cupertino
ago t llablllti a, jad rat., and expenseswhlch mayfn anywayaccrue
Date ReteiPt#
ALTERORADDTOMECH.
AIR HANDLING UNIT (TO 10,000CFM)
SUBTOTAL:
a tsald Cl In asequen of the granting of this pe
MqL
AIR HANDLING UN7T(OVER IO,ODDCFM)
CONSTRUCTION TAX
o pph ontractor Da
EXHAUST HOOD (W /DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS A ERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Date Recei t#
lli appllontorfuture Ildf occupantstoreorhandlehavrdous
al definedbythe Cu lno unicipal Code, Chapter 9.IZ and the
:Hk.1th d Safety Co de Settio (aH
ca �] No
Will the applicant orfuturc building occupant use equipment or devices
HEATING UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RFSID)
ISSUANCE DATE
which emit havrdous air contaminants as defined by the Bay Am Air
Quality Management District?
Y. p No
4 have ad the hug ous materials requirements under Chapter 6.95 of
AID
BOMER.COMP DELP OR 100,000 BTU)
BOILER- COMP (OVH2100,000BN)
the Gilfornia I iealth & Si fety Code, Se tfons 75505, 20 and 7:534. I
andesta ad that if the building does not currently have a tena nL that it is my
resporulbllity to notify the occupant of the requirements which must be met
��� ' 992
NEW RrMDENIIAL MECH. SQST
prior to Issuance of a Certificate of Occupancy.
1s�7A�(�/'�
C11 Y ur 4 rfJe.j/I
ISSUED BY:
Owner oraulhofireda rat Date
6e
TOTAL:
OFFICE COPY