23669APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
""Baing Addre : /
S,
PERMITNO.
23669
wee a one:
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
BUILDINGELECTRICAL PLUMBINGMFCHANICAL
(,j �'�J
l_ o s _ l'
c°n rad Mame: LIe.N°:
Architect/ gllunr. Lk. No:
CATEGORY CONTROL N
QTY ELECTRICPERMIT FEE
BUILDING PERMITINFO
Address
❑ ❑ ❑
PERhITISSUANCE
LICENSED CONTRSDECLARATION
I hereby under
ectionaffirm lhm lam licensed underpessand sof Cssions9(emmen
Ingwith5edlon 7000)o(DiWelon3ofthegudncaeand Professions Cade, and my
Lim Is In (u force and died.
Liana lace i Llc M ,�
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
i $
PANELS
PANELS
to
Dale Cantndor ��.�UP
TO 200AMPS
201 -IMO
ARCHITECPBDECGRATION
]understand my plans slug be used upublic rem
records.
OVER 1000 AMPS
OVER
SQ. FT. FLOOR AREA $/SQ. Ff.
SIGNS ELECTRICAL
Licensed ProfessiarW
DECLARATION
OWNER -HOLDER exempt
I hereby afollowing ffirm that 1 am exempt from the Contractor's . Codes law for the
=Atywhlchmqu( aon76d1$Bustmdand Professionsemle hnydtyor
anystm mprirtoi per nce,al mquialttheapmvntfor.bh,arrepair
any nlmdure statement
ecet licensedpursuant to the fornuch s of the
that
(Ile a signed statement that he t Ilrensed pursuant to the previsions of the
Conlndor'e License Law (Chapter 9(rommenciogwith Sedlon7000)of Dtvl-
don3 afthe Busl ..d Prof.Wro Code) orthe he [exempt them(mmand
SPECIALCIRCUIT/MLSC
TEMP. METER OR POLE INST.
IY))WFR DElICFS 1
' A
, V
IC's
P T E R
TION
SWIMMING POOL ELECTRIC
the basin for the alleged exemption. Any violation of Section 70715 by anyOUTLETSSWIICH[SHX'IURFS
applicant fora permit subjects the applicant to a civil penalty of not more than
five 1, A. undreowner
demodollarthepr).
�I, ac owner of the property, or my employee with wages [herr sole
NEWRESIDENTIALELECTR SQ.FT.
STORIES
IYPECONSMLJCT0N
s wdlldothe workand the intended o r
.]aC 7044, Coduretnot loffendfor
dale (Sec. Professions Code: The Contractor's Llama Law
apply to anowand
docs not apply roan owner of through
yiswho
who e nempoymprwnthereoMand
throffe hisorsemployees,provided that such
OCC.GROUP
RES. UNITS
ovdoes nc amworkM tendolf
improvement arc nor intended oro(fered foraale. IS however, thebuilding or
improvement issold within one yearof completion, the owner-bullderwill have
TOTAL:
tfIl,4urden of proving that he did not build or improve for purpose ofsele.).
jL jj 4 as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7614, Business and Professions Code:
QTY. PLUMBING PERMIT FEE
ppRMITISSUANCE
, 5
FLOOD ZONE
APN
The Contradoe, License Law dm not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such pla)eds with a
ogptrador(n) homaed Commences to the Comeoes License Law.
0I am exempt under Sec. B k P C for this mic en
ALTER -DRAIN 4 VENT WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT.OEVICE
OUTSI � FEIIS
DRAINS FLOOR ROOF, AREA, CONTI.
SANITARY Y N
RECEIPT N
Owner Date
WORKMAN COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self-lnwre, or
a i cateof Workem'Compemationlr mncemacertBledcopythereof6ec.
3800, lab C n /� e}
Pollry
ptt.�gp$I,pR.l.�r
SCITOOL TAX Y_ N
RECEIPT N
GAS. EA. SYSTEM -1 INCA OUTLETS
PARK FEE Y N
RECEIPT N
S
GAEA. SYSTEM -OVER 4 (EA)
Com
BUILDING DIVISION FEES
Certified mpytherebyf
CertBled mpy t flied wllh the city irupection division.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thleeedlon need Act be complded lithe perch[ t furors hundred dollars
($100)arlem.)
I certify that In the perimeranceof thework forwhl6 this permit is issued,
I shall not employ any person In any manner do se to become subject to the
Worken'Compenxtion Lawsof California. Date
PAID
Date Remi tN
SEWER -SANITARY -STORM EA. 201IFT.
WATER HEATER W/VENT/m cr.I.R
ENERGY FEE Y N —
PAID
WATER SYSTEM/TREATING
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Workeri Compensation provision, of the Labor
Code, you at forthwith comply with such Imminlms orthis permit shall be
deemed revoked.
Date Rea!IN
NEW RESIDENTIAL PLMO. gQT•T.
TOTAL:
13UILDINC FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there Is e construction lendingagency, for the performTOTAL:
ance of the work farwhlch this permit t e 309]
issued (Se, Civ. C.)
Iand.e. Name
Lenders Aadrex
I cmifytha I have read thisapplication and state thatthe above Information
lectured. I agree to comply with allcity and countyordleancea and state lawn
So
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMITISSUANCE
FEES PAID:
relating to building conatroction, and hereby authorise representalves of this
city to enter upon the above-mentioned property for inspection purpoe's.
(We) agree to save, Indemnify an d keep harmless the the City of Cupertino
ALTER OR ADDTO MECH,
Date Revel 1N
P
SUBTOTAL:
against liabNlies,judgment, mats and expenses which may in any way aeee
Ireteaid Cltyln glna ofthe granting of this permit.
� �49y
AIR HANDLING UNIT CTO 10,000 CFM)
AIA HANDLING UNIT (OVER IO,ODOCFM)
CONSTRUCTION TAX
ou
atomofA c t cii(fnctar ate
DcHAUSTHooD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UMT(TOI0),000BTU)
Willtheapplicant or futtre building occupant store or handle hazardous
material an de0ned by the Cupertino Municipal Code, Chapter 9.17, and the
I ealth and Safety Code Section 2SS37(a)?
No
Yea No
Date Recei tN
HEATING UNIT (OVER 100,0^0 BTO
TO
VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
Q'�
P A U D
WIIltheappiionl m Wilding oavpantuse equipment or devices
which emit hazardous air meta mina ots as defined by the Bay Area Air
Quality Management District?
[ Yes N No
havereadthett,& fuyC de,SemqulrementunderChap(e4.I of
the CaII(mnt Health k safety Code, SMION 25505, 25533 and 75534. I
BOILER -COMP QHP OR 100,000 BTO
IIOILEIi-COMF(OVER 100,00^07V)
NEW RESIDENTIAL MECH. SQ.FT
understand that lithe building does not currently have a tenant, that It is my
rmporoiissanceity to nfafytheicte ofOrfpancy. requirements which mustWmet
priorns issuance ofdy the co to oft of the req
SEP 17 19
�.�� �y
ISSUED BY�LIC Vl1.{' iI IINU
Owneror authorized a gent Date
TOTAL:
Kim B�1
OFFICE COPY