23172 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PMMIT NO.
,sliding Address: 23172
eeReP1�1 r�-
Owners N.: More:
CITY OF CUPERTINO-BUILDING DIVISION n
con actor'aName: Lie.No: APPLICATION / � —
PERMIT q1 q
2.
BWLDINCELECTRICALPLUMBING-MF HAMCAL CATEGORY CONTROL#
AmMtM/Engineer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address
PFTttATI55UANCEI ❑ ❑
LICENSED CONTRACTOR'SunderDECLARATION �-U
I hembyaf(irmthatlam Bcrosdhe Busl ossand Pro Chapter9(commme AI'1'1-IANCESRESIDENTIAL JOB DESCRIPTION
It...i Section force and
ofthe Bupussand Pro(evion.CAde,and my qp�s
license lain full force and effect. PANES Cal-)
��
Date
License Ch. Lk.N ✓l
Date Contractor
ARCHITECT'S DECLARATION 201-IOW AMPS
ca Z I understand my pla®.hall be used as public records OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
do OL138n d Professional SIGNSELECTRICAL
FUSI
A L E D IN
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC p U T E R
IhembyafOrm thatlam exempt(romthe Comractorb Llcerue law(or the
folowing reason.(Se lion 73815,Bueinen and Pm(cnlons Code:Any tlty or
O F. 'RMP.METE2OR POLE!NSI.
l' county which requlreea perMttocomtmct,altegimprove,demolish,orrcpair
anystm=mpdortultsbarance,alsorequimatheapplmntforsuchperMtto POWER DEVICES
�e file a signed statement that he Is Ilcensd pursuant to the provtviom of the — OATS
�Oa
Contractor's License Law(Chapter 9(mmmencingwith Section 7000)ofDivi. SWW.MINGPOOL ELECTRIC
iaaaaVALUAT
F�Oa slon I ofthe Bugeassand PenfesslonsCds)orthat hob exempt therefromand �`.
G 6.5 the basis for the alleged exemp Ilan. Any violation of Sectlon 70315 by any 1
OQ applicant fora permit subjectatheapplicam a mreOUTLETS-SWITCHES toe civil penalty dna l
pa F five hundred dollars(SSW). NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPECONSTRUCTION
O �n ❑p� I,as owner of the property,or my employees with wages as their sole Z compensation,wltdothe work,and thestructure b not Intended or offered for
.1.(See.7004,Business and Predook s,Code:TM Contractors License Raw
(�s$ does not apply to an owner of property who Wilda or improves thereon,and OCCGROUIs RES.UNITS
E who doessuch work htemB
eur through his own employees,provided that such
Improvements arc not Intended oroffered forvle.If,however,thebuilding or TOTA :
Improvement bsold within oneyearofcompictlon,the owner-bullderw111 have ar
tl,iturden of proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEF.
FLOOD TDNE APN
u L as owner of the property,am sacluaively contnRing with Limned
PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractor's License Raw does not apply to an owner of property who ALTER-DRAW&VENT-WATER(FA)
Wilds or Improve thereon,and who common, for such p4ojecn,with a FEE SUMMARY
Cg0.t c, r(s)Bernard pursuant to the Conteacters License Law. BACK FLOW PROTECT.DEVICE
LJ 1 am exempt under Sec. B &P C for this reason
Owner Data DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N=
WORKMAN COMPENSATION DECLARATION RECEIVEN
F11
hereby affirm that I have a certificate of consent to self4esure,or a fl%1LRES PER TRAP SCI-1001,TAX Y N
RECEIPT N
3800,1.b C.) orkeniomperwatiop-Ira/yr�ayce�^ led mpythereoft5ec. GAS EA.SYSTFM-1 WC.40I17LEf5 PARK FEZRECEII'fN
Policy. p GAS EM
EA.SYST -OVER 4(EA)
Cary s.•- BUILDING omg
.Nary
copy b hereby furnished. CREASE/INDUSIRL WASEIN"f'FRCE'TOR PLANCHECK FEE
r2eva—tfled copy b filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-SHAM EA pNrl• Date Recd tit
(fhlssection need not be completed If the permit is forces hundred dollars
(31000Orlen.) WATER HEATER W/VENT/ELLCTR ENERGY FEE Y N
certify that in the performance olthe work(orwhlch this permlt is Loved,
I shall not employ any person In any manner an as to become subject to the WATEt SYS1TM/TRFA'IING >
Workers'Compensation paws of California. Date PAID
O Z Applicant NEW RESIDENTIALPLMB. JFI. Date Recei tN
Z O NOTICETO APPLICANT:If,after makingthb Certificate of Exemptbn,you
should become subject to the Workera'Compensatlon pro o,knoiof the Labor TOTAL:
CC CO Codeyou=at forthwith complywithsoch proWlom orthb permit shailbe
W > BUILDING
deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
41 I hemby affirenthat there b a construction lending agency for the perform- ELECTRIC FEE
M Z ance ofthe work for which this permit is Issued(See.3097,Civ.CJ TOTAL"
02 Lender's Name PLUMBING FEE
U. F Lenders Address QTY. MECHANICAL PERMIT FEE
O W Ice0lfythatlavemadthtsappllcatlonandtatethattheabovelnformation MECHANICAL FEE
4 bcorrect.I ageeetocomptywith al cityand countyardinancesand pate laws PERMIT ISSUANCE FEES PAID:
relating to building coretruction,and hereby authorize representatives of this
N city to enter upon the above-mentioned property for Inspection pu rposes. ALTER OR ADDTO MECH.
Z (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
V aganotlh Ilm,pdgments,cops and expenses which may In any wayacvue ARRHANDENGUMT(TOI0,000CFM) SUBTOTAL:
ainsts Ity nroone reef granting OfAis permit.
�J AIR HANDLING UNIT(OVER lO,WOC1'vM) CONSTRUCTION TAX
Sigwtureo(Applicant/Cqp nor s Data IXw UST HOOD(w/DIKT) CONSTRUCTION TAX PAID:
HA2AR O IS MATERIALS DISCLOSURE
Willtheapplcantorturebulldingonvpantstoreorhandlehazardous HEATING UNIT(TO 100,ODO BTU) Date Receipt
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Ir,.hhand SaflyCde Sel1on25532(a)2 HEATING UNIT(OVER I00,ODO BTU) TOTA .
❑ Yes M No
Will the applicant orfutum building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSLJAAC'E DATE
which emit laza educe air roma ormants as defined by the Bay Area Air Q�Na A
Quality MawgementQNBOILER-COMP(3HI'Oft IW,O(p BTU)
Y o
No
have read the
Health
Tet materialsdSectio remenb5533 an 2553. 1 of BOILER-COMP(OVE4100,000 BTU) JAN O8
the California Health&Safety Code,Sectiorently have.
I11
understand that lithe building doe,not currently haveatenanq that ltbmy NEW RESIDENTIAL MCCH. SQ.IT.
raporoibileoccupantm
y to notify the opant of the qW ukeme is which most met 0I y
prior to Issuance da Certificate of0ccopanry. Y Uf LUrtI'(I INV
4
Owner or auth.HmA agent Date ISSUED BY;
TOTAL:
OFFICE COPY