23278 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
B.Ildhig Peeled Identification PERMIT
PERMIT NO.
enuring/a3 / N/�G�D ��y� 23278
mer ame: L /v one: A
=aL �/(3 /3 2�cJ CITY OF CUPERTINO-BUILDING DIVISION
Coals raNa : Lie.No: APPLICATION /PERMIT 3 as)Adh
Q �2 �- Q L/ BUILDING-ELEC7RICALPLUMBI NG-MECI IANICAL CATEGORY CONTROL
Architect/Engineer: /Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby vmot�halam
hearedi
aGunder
S,Son9sofChapter 9 < APPLIANCES-RESIDENTIAL JOB SRIPITON
inaction70000/)iWsion3oftheguMnmandPm/mionsCode,and my
license
YPANELS
Date`3�Contaeor — 1TJ��rJ A
RCHITECT E RSU CW ION 201-1 ODOAMIS
�7 I understand my plans shall be used as public records. OVERIODOAMPS SQ.FT.FLOOR AREA S/SQ.FT.
Ho
SIGNS ELECTRICAL LED
I
z�j Licensed Professiansl L IN
�Q OWNERBUILDER DECLARATION N
le SPECIALCIRCT/MISC
Iherce
byatOrmthatlam exempt from the Contractor's Llrenx I..for the
0Z following reason.(Section 7071.5,Business and Profesems Code:Any city or TEMP.METER OR POLE INSP.
I"' oountywhich rcqubesa permittomnstmct,ilter,impmve,demolbh,orrepair
AT
anystructure priorto Its issuance,also realuircstheappmet fmrsuch permit to
['OWER DEVICES
� Ole a signed statement that he V licensed punuant to the provisions of the
X3µ . Contractor'sLicense Law(Cha pter9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
W�Og slon3 ofthe Business and professionsCode)orthat he a exempt therefromand VALUATION
Q 5 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESIX
FTURES /
applicant(ora permit subjects the applicant to a civil penalty of not more than
p... O five hundred doll..($500).
$, NEW RESIDENTIAL ELl:CTR SQ.IT. STOWP TYPE CONS'IRIX:7'ION
7 ❑I,as owner of the property,or rtes employees with wages r their sole
mm(Sce.7lom Business
the work and the ions Code:T V not intended or offered for
p sale(Sec. pply to an owandf property Code:The Contractor's License law
dixes$ and
who dor a ssuch torn owner otpmp h his one mpIyces,povideds or impareen,t I mguch OCC.GROUP RFS.UNITS
whodoessuchwork himselfmthrough Msowna.ILhowepertheedthei gor
Improvementsarenotintended earisfoo forsale.I(howevcgthebulIl1 have TOTAL:
Improvement provisold within one id not huild o ice the a fee
erbugde of sehave
t4,.pmben ofprovingof the
build or improveefactingpurpose license QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
Lu L as owner of the Property,am exclusively contracting with licensed PERMIT ISSUANCE
the Ccte.to rs Lien the project(Sec.apply
Business and Professions Code:
the Contractor's Wenx Law does not apply tct an owner of property who
buALTER-DRAIN&VENT-WATER(EA)
Wilds or improves thereon, and who contracts for such p(ojecta with FEE SUMMARY
9)licensed under
Sec.
the Contractor's License Law. gAIX FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B &P C for this reason
OUTSIDE Fl Vs
DRAINS FLOOR A,ROOF,ARECOND. SANITARY Y N
• Owner RECQI'T
KMM
WORAN COMPENSATION
ARATION FDCIIIRFS PER TRAP SCHOOLTAX Y_ N_
❑I hereby af(vm that I have a rertiRcate of consent to xl(-Imre,ora RECEIPT P
ceri(Imteot WorIums Compereatimn lnsurane me emitted copy thereof Sec. GAS EA.SYSTEM-11NCA OUTLETS PARK FEE Y N
M00,FabC) O
puul # //,/% /0 7P GAS G.SYSITMOVER4(G) RECEETN
Gam any l cad / Rel /' BUILDING DIVISION FEE
Certified mpy is hereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCI-IECK FEE
[j].feHffied copy b filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORMG 200Ff Date RCCCI IN
(This a ionneednotbecompletedifthepermitisforonehundreddollen
(S11D)Orless.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
I certifythat N the performance of the work for which this permit is Inexact,
1 shall not employ any person In any manner so as to became subject to the WATER SYSTEM/TREATING
Worka.'Campensatmm Laws of Ce forma.Date PAID
OZ Applicant NEWRF9DPN77ALPLMB. QFT. Date Recei IN
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
CCN Code,you must forthwith comply with such provisions orthle permit shall beBUILDING 7'E
deemed revoked. SEISMIC FEE
W 7 CONSTRUCTION LENDING AGENCY
1 I hereby affirm the there is a canstrur ion lending agency for the perform~ ELECTRIC FEE
7 Z an"
.(the workforwhlchthis permit is beard(Sec.3097,CMC.)
U TOTAL:
O I<nder's Nam PLUMBING FEE
LL I— Lcreive.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U IreNfythat l have mad this application and statelhatthe above lnfmrmation
O W Is carrect.Iagree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. M relating tobulldingcanstructfon,and herebyauthoeiuepresentativero(this
(— Z city to enter upon the abovo-mcntimud property for Inspection purposes. ALTER OR ADD TO MECH. Dale RecciplN
(We)agreee�to save,Indemnify an d keep harmless the Ctry mf Cupertino
V agaWtl fRles,pd ma,cossandexPPP$$$^^^ s which may in any wayacerue AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL:
against d"Ci In nsequenre he gr{Rlag of this permit.
AIR HANDLING UNIT(OVER IO,ODOCIM) CONSTRUCTION TAX
Sign re of Applicant/Contractor/` Data IXHAl15'T HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appllunt or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Rec
material as defined by the Cupertino Municipal Code,Chapter 9.1Z and the
HealthandSafety Ccde on M"(a)? HEATING UNIT(OVER 100,000 BM TOTAL:
F1 Yes
' Will rhe applicant cartuturcbulldingompantux equipment or devices VFNUG710N FAN(SINGLE REBID) ISSUANCE DATE
which emit hamrdoes air containments as defined by the Bay Arca Air
Quality Management District? BOILER-COMP(3HPOR 100,000 BTU)
4Yes FI�:v-I'�Nw��,�o
M1averesdthe hazardous m ode,Section 2555,2553 and 255 6.95 of BOILER-COMP(OVER 100,0008TU)
the understand
nth Health&Safety Cove,Sections 75505,have
a t and 15534. I
understand that if the building
eoccepdoes net mrrently have atewhL that It mets NEW RESIDENTIAL MECH. SQ.IT. V' /� B
roponsibllil to notify the occupant of there mentswhicM1 must be mu-[
Flee
tot nm ofa Certl(Icate gtO�an Ve q ^ y
Owner car m authonDae
TOTAL: ISSUED BYxrx—
Ivu
OFFICE COPY