23004 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PFJMTNO.
Building Address: 23004
I �6ti 9a L4
am: I Fhonc:
CITY OF CUPERTINIZ BUILDING DIVISION ry 1
. Cont dor' r"e' /t Lim.No: APPLICATION /PERMIT I If T CIA J
�' e/f BUILDINGELECTWCALPLUMBINGMECHANICAL CATEGORY CONTROL#
Anc.../unguxen Lim No:
QTY, ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: L-�✓ PERMITISSUANCE N %g ❑ ❑
LICENSED CONTRACTOR'S DECLARATION L]�
I hth Sb ion7OOfirmtha lam ivigolicensed 3oftheunder ukp saemolehonsr9(commac- APPLIANCESRESIDENTIALingwi ]QB DESCRIPTION
licer.hSMlon TORI)and efelon3 ofthe Buaneseand Pro(eseloneCode,and my FM__QB
-
II«vessel as and Lima.. CjfYQ PANELS R r1 1�DT�
License see Lk# J7 ( V
Dale GonlradorLIE TO 200 AMPS L
ARCHITECTS DECLARATION 101-1000 AMP"'
q�q�vv p❑O I understand my plane shag 6e used as public records OVER 1000 AMP$ SQ.FT.FLOOR AREA S/SQ.FT.
Fi [) Licensed Professional SIGNS ELECTRICAL A L E D
OWNER-BUILDER DECLARATION $pp-CJAL CIRCUIT/MLSC
Ihereby of rmthatI am exemptfromthe Contractor's License Law for the
countyrequiresta permit tocoprovoar
. M P' p,Ufollowgmo .(SMIan7RI15,BuainmandPmfmi.n.Cde:An tl tyar TEMPMETER OR POLE INST.
nycture iorto its haotomquistheantforsudi, omitin POWER DEVICESfile a signed statement that he Is licensed pursuant to the provtmes of the
6 Contractor's License Lw(Chapter 9(commencing with Section 7000)ofDivi-
3 sion 3of(heaueine..and Pro(eulom Code)orthat he t exempt lherefromand SWIMMING POOL ELECTRIC VALUATION
the ball.for the alleged exemption. Any violation of See lora 70315rean s►r"'e
p 6 epplIamit
ntforapersubjMstheapplicanttoadvllpenaltyofnatmorethen ` Colo
D
five I,as
neroft(f5(10). NEW RESIDENTIAL ELECTR__SQ,FT. STORIES TYPE CONSTRUCTION
z p, ❑I,ae owner ll rho properly,or my employees with wages r Their dole
compensation,wllldolhe work and Ihearucturc Isnot Intended or a!(emd for
sale(See.7044 Buslncu and Professiom Code:The Contractola License Lw
S� docs not apply to an owner of property who Wilds or improves thereory and OCC.GRONr RES.[IMUS
whodoessuchwurkhimselforthrough hidownemployas,provided that such
Improvements are not Intended orofferedforeale.If,however,thebullding or TOT.&
improvement tsoldwlthln omyearo(completlon,theawner-bullderMll have
flIlLtiturden of proving that he did net Wild or improve for purpose ofulm). QTy, PLUMBING PERMIT FEE FLOOD ZONE APN
Lj I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
mnuactors to mmtrun the project(Sec.7044,Buaneae sed Profeubm Code:
The Contractor's License Lw does nor apply to an owner of property who ALTER-DRAIN A VENT WATER(EA)
builds or Improves lhereoq and who contracts for such p4o)ects with a
e
gtilador(s)licensed pursuant to the Contractor's License Law. FEE SUMMARY
l_f I am exempt under Sec. B 4 P C for this reason BACK PLOW PROTECT.DEVICE QUTSIDIIFEES
Owner ae
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
DRECEIPT a
WORKMAN COMPENSATION DECLARATION FDCIURE_S PER TRA SCHOOL TAX Y N
❑1 hereby affirm that I have a Incenone of consent to op thereof
ora RECEIPT I
3800,Lcertificte Lb
Warken'Compewtlonlmurana as certified copythereaf pec. GAS EA.SYSTEM-]INCA OUTLETS PARKFEF. Y N
Polk 0 CJ
Cam an GAS EA.SYSTEMOVER 4(EA) BUILDING
IV
y {� BUILDING DIVISION FEES
�C difle coyie hereby ml.h CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
�ertlRed copy t filed with the city inspection division. ,
CERTIFICATE OF UEMPr1ON FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE
(This section need not becompleted lithe permit isforonehundreddollan gE}yp-RSANITARY STORM EA•2WFT. Date Receipt#
(510))otifyth WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I snot that In theperson
Iperformance n tmannerhe work(n as,to becomh this e rmit
c teed,
I shall not employ any person In any manner n u to be ranee wbjM to the WATER SYSITM/TREA'DNG
Workers Compensation Love of Gllfomt.Dale PAID
O Z Applicant NEW RESIDENTIAL PLMR. SQFT. Date Remi t#
Z Q NOTICETOAPPLICANT:If,cher making this Certifla/e of n,you
should becomes ho&to the Wmi ra'Compenaatlon prcwlI llhe Labor TOTAL:
L
Cude,you most forthwith comply withsuch pnevlalcuumtht pertNtahallbe ��-
W j deemed revoked. BUILDING FEE
a c CONSTRUCFIONLENDING AGENCY SEISMIC FEE
Ihereby.Mrm thatthemi, comtrudion lending agency forthe perform ELECTRIC FEE
Z ane of the work(orwhich thtpermit t Issued(Sec.31 N%,Civ.C.) TOTAL:
U O knder'.Name PLUMBING FEE
IL F Lender.Addrese QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW 1 outtly that l have read this application and Mate that the above Information
(L Is l agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
W relating to Tiding amwction,end hereby authorize representatives of this
Z city to entr pon theabove-mentioned property for Inspection purposes. ALTER OR ADD TO MECH. Date RCCCI [#
V _ (We) gr a to save Ind n d keep harmlen the City of Cupertino P
agalmtl b tice,Ndg de ndexpenseswhlchmaylnany aye a AIR HANDLING UNIT(TO I0,0D0 CFM) SUBTOTAL:
aguimt 1 by boons dna /he gran U.Softhiepermlt.
AIR HA NDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signa o App ca ontre
Wit E3(HAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
H RDOUS MATERIALS DISCLOSURE
Will the applies or future building occupant store or handle hazardous IiFATING UNI:(TO 100,000 BTU) Date Recei t#
material..de fined by the Cu At Mu end .1 Code,Chapter 9.1 7,and the -
HalthendSafdyCodr on 15532(a)T HEATING UNIT(OVER 100,000 BTU) TOTALIOMW
❑Yea No
Wlllthe applicant r utum building oovpanl use equipment or devices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which emit havardous air centamlrunt.as defined by the Bay Arca Air
Quality Management Distrid7 BOILER-COMP OHP OR 100,00(/BTU) (� A B
❑Yes n❑No P A
(have read the baealloua
materials requirements underChapler 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health A Safety Code,Sections 75505,15533 and 75534.I NOV
understand that lithe the occupant
not erequ It haves tenant that It troy NEW RESIDENTIAL MECH. SQ.FT. 1(301
responsibility if tifythe the occupantn thercqulyhave s whichmuet It mel aJ���77 YY
prior to Issuance of a Certificate of Occupancy.
CPfY u
Owner or authorized agent Data ISSUED BY:
TnrnL:
OFFICE COPY