23335 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE B LL POINT PEN ONLY
Building Project Identification W
PERMIT NO.
103,;1 J I1Ak ZAoQ D12 -LII71 tj 23335
�t^nere ams: A .
l—tEb �- RF—E 1� '�S �S7e' � CITY OF CUPERTINO-13UILDING DIVISION
cue e, Ca d r'e Nam': k No:
APPLICATION I PERMIT CATEGORY CONIROLa
rr��WWeel/En neer. 1 BUILDING77.ECTRICALI'Ll1MBINGMFGHAMCAL
'•;d•F'' ) C� R>✓�C„ UN- 0IJ LIC No. BUILDING PERMIT INFO
�/I O7Y ELECTRIC PERMIT FEE
AddB= I PLUMB MDLtl
ress: /C7�3 tb9/VhIU M PERMITISSUANCE [ILICENSED CONTRACTOR'S DECLARATIONIs
�
T hereby affirmthat lam licensed under provisions o(Chapler (romme� APPLIANCE -RESIDENTIAL JOB DESCRIPTION
IngwlthSedion7000)of Di.1.1.n3oHheBuslnemandProteWmsCode,and my
"can
ee le In(uR Ire and.(fed, PANELS
Llmn.e ClaesLic.N
Dan. 2__=_lr..ContractorLIP TO 200 AMPS
ARCHITECTS DECLARATION 201-1000 AMPS
�ppya+�O Zp I understand my plans shall be used as public records OVERIOWAMPS SQ.FT.FLOOR AREA $/SQ.Fr.
E'Od of Licensed Professional SIGNSELECTRICAL
�6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
I heeeby afOmi that I em exempt from the Contractor'.License Lw fm the
following reason.(Section 70115,Business and Professions Code:Any city or
H 8 TEMP.METER OR POLE INST.
FEI
county rcqulresapermite,also require.
theapmvgdemsch,erto
< any a signerepdomentthar to Its he Is limnequlrcetto the
suchpermit e POWER DEVICES
�w V Ole a actors statement that het licensesencing pursuant it the tion 7000)of
of the
3 eco go.Con3ofilhe°sense itPnoapter9(commentlngwith xemprttherefom.tul gWP1h9NG POOL ELECTRIC VALUATION
slon3o(the Buelnene ons ProfealonsCode)orthat hebexemp[therc(romand
< the basis for the alleged exemption. Any violation of Section 70115 by any OUTLEISSWITCHFSFIXTURES
p applicant fora permit sub*ta the applicant to a civil penalty ofnat nerethan
Ove hundred dollars($.A%. SQ.FT. STORKS TYPE CONSTRUCTION
NEW RESIDENTIAL ELECTR
<n ❑compensation,ss owner of the property,ar my employes with wages r thele dole
I-(Sm.7044will dothe week,and the stmde: Vnot Ntendedo iofferedfar
q dale(Sec.7 ply Buenos and f property Code:The or Improve,
ove,Ihre m Lw
does not apply to rk owner of property who builds or Improves thermR and
�^
.he does such work himself orthrough hlsownemployees,provided that such OCC.GROUP RTS.UNITS
Improvements are not intended oroffered(mule.If,however,thebullding or
Improvement hsold withinoneyearofcompletion,theowner-bulWerwlll have
tt .Lmeden of pmWng that he did nor Wild orlmprove for purpose ofsale.). QTY. PLUMBING PERMIT FEE ---TLOD ZONNE APN
u I,as owner of the property,am exclusively contracting with licensed
contradost..oncud the project(Sec.7044,Buslnm and Professions Code: PERMITLSSUANCE /•
The Contractor's License Lw dote not apply to an owner of property who
Wilds or Improves'hereon,and who contracts for such pVjcd.with a ALTER-DRAIN A,VENT-WATER(RA) sa�
c -r(s)hmosed pursuant to the Contractor's License Lw. FEE SUMMARY
[_JI am exempt under Sec B k.P'C for this reason BACK FLOW PROTECT.DEVICE
OUTS I DE ITES
tf T Owner Dee DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
RECEIPT#
WORKMAN COMPENSATION DECLARATION SCIi00L TAX Y N
�•
01 hereby affiren that I have a certificate of consent to self-Nsure,or pp(NgEg PER TRAPRECE NN
certificate ofWorkeri Compensation Insurance or a mrtlfled copy themof(Sec.
3800,1abC.) GAS.EA,SYSTEM-1 WC.40ITILETS PARK= Y N
/
Pol icyp GAS EA.SYSTEM-0VER d(EA) RECEIPT#
Co a y - R UILDINC DI VISION FE RS
Certified copy V hereby th the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy is filed with the city Inspection division.
CERTIFICATE OF EXEM PTION FROM WOR KERS' GREASE TRAP PAID
COMPENSATION INSURANCE - SEWER-SANITARY-STORM EA.200FT. Date Recei t#
(This section need na be completed if the permit h forone hundred dollars
($]°°)°Test.) WATER HEATER w/VENT/EI,pLTR ENERGY FEE Y N
I rertifythat In the perfomunce of the week for which this permit is ensued,
I shall not employ any person In any manner so u to become subJeci to the WATER SYSTEM/TREATING
Workem'Compenmtbn Lws of Gllforn a.Date PAID
O Z AppliNOTICE NEW RESIDENTIAL PLMB, SQ.FE Date Recei t#
Z O NOTICETOMPLICANT:R,ager rs'Co this Certificate pro ofExemption,oft the
should become subject Toth.Workers'Compeneatlon proWloeu o(lhe Labor TOTAL:
W Code,you moat forthwith comply with such provisions or this permit shall be BUILDING FEE
W j denoted revoked.
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hercbyaf(Irm that there It•construction lending agency faiths perform- ELECTRIC FEE
M Z ance of the work for which thin permit is tewed(Sec.3097,Civ.Q
U O Lender's Nam' PLUMBING FEE
LL I— Lender's Address OTY. MECHANICAL PERMIT FEE MECHANICAL
OW I certltythatl have read this applicztlonand sratelhe theabove information
a Nom tt.f agree m complywith all city and county ordinances and date laws PERMITISSUANCE FEES PAID:
r relating to building construction,and hereby authorize mpreeenta0vee ofthla
I— U) city to enter upon the above-men0oned property for Im,;Nonpuepox.. ALTERORADDIT MECH.
V — (We)agree to save,indemnify an d keep harenlem the City of Cu portio, Date Recei t#
agabut liabilities,pd manes,coesand expenses which may In any wayacerue AIR HANDLING UNIT(170 10,W0 CFM) SUBTOTAL:
against mid Clty ns uence of the grant int of this permit.
AIR HANDLING UNIT(OVER 10,0(IOCEM) CONSTRUCTION TAX
Slgwtureo( ppRmnt/Contractor Ditfi D(HAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant atom or handle hazardous HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Mu nicipal Code,Chapter 9.12 and the Date Recei t#
Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Y. fiJ1 No
Will the appBnnl or tum building occupant useequipment or device.4
7. VENTILATION mh:(SINGLE RESID) ISSUANCE DATE
which emit hmardous air contaminants as defined by the Bay Area Air
(Quality Management District? BOILER-COMPOHPOR100,0(10BTU) p
❑Yee , mi NV
' haveID
'rad Tralth ar�i No.
Sectors
25505, underChap(er. 1 of BORER-COMP(OVIB 100,00(1 B'R)
" `theCali.odth,tifth kSafetyildig odr,Sedlm ntlyh.25.3a.dt th34. I FEB 24
understand Ther ratify
the occupant of t erequi hamto which
that it met NEW RESIDENTIAL MECH. SQ.FT 1rC_F'"
responsibility to notify the occupant o!the requlremenla which nest be net 1
prior to issuanre of a Certificate of Occupancy. CIry Ur I/Ur
Owner or authorized agent Data RUED BY: Vs!/YI 1
OFFICE COPY