23167 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project IdeNllication , I . PERMIT NO.
Budding Address: 23167
wre '
Oea svc t h wa-
ncante: one:
CITY OF CUPERTINO-BUILDING DIVISION A .j
tradora Name: `' LICNo: APPLICATION /PERMIT `
BUILDINGELECTRICALPLUMBING-MECk1AMCAL CAT!LORY CONTROL N
Archlted/Englocer. Lit.Nr:
QTY ' ,ELECTRICRERMIT 'FEE BUILDING PERMITdNFO
. Address: PERMITISSUANCE I� ❑ ❑ 1111LICENSED CONTRR
AOR's DECLARATION Ln
I"by
that[am licensed
under provisionsof C9(commmc AIPLIANCESRESDEN7IAL
ingwithScton7D00)ofDivlslon3oftheBusnessandPmlessionsCode,andmy
license
Is in l ll,pMaad effect. � O t,31 PANELS .
Irensc Class 11?? Lk.0 1 ( r0
ate-��la�t-�C.Mmcmr 3 �'.—Qa—^ sG
ARCHITECTS DECLARATION u— 201.1 WO AMPS
q�q�uu� Iunderstand my plane shall be used as public records. OVER TWO AMPS SQ.FT.FLOOR AREA $/SQ.FT.
S Licensed Professlovl , SIGNS ELECTRICAL
�<<6 OWNER-BUILDER DECLARATION SPECIALCRtCNT/MISC
7p, Iherebyaffirenthat l am exemptfrom the Contractor's License Law for the
O H following reason.(Section 7031.5,Business and Professions Code:Any city or TEMP.METER OR POLE INS
F� countywhichrequlreeapermlttommtmMalter,4npmve,dem lWh,ormpalr
-NaiE
rudurc prior to its issuance,also requlmthe applicant for such permit to POWER DEVICES
q
Nfila signed statement that he Is licensed pursuant to the provblom of the
O Contractor's License law(Chapter 9(commencing with Section 7000)of Dlvl-
I,•�OS slon3olthe Bueinoaend Profenlons Code)orthat heis exempttherefmmand SWUfA9NC IDOL ELECTRIC VALUATION
as the basis for the alleged exemption. Any violation of Section 7031.5 by any - �C% . O f
CJ
appBcant for a permit subjects the applicant to a civil penalty of net more than OUTLET&SWITCHESFIX7T1IiE5
E o five hundred dollars(S ML NEW RESIDENTIAL RLECTR -
WW ❑I,as owner of the property,or my employees with wages as their sole �'hT' SfO1BFS TYPE CONSTRUCTION -
s. cmpensation,wiR dothe work and the structure b not intended or offered for -
^5 Ole(Sec.7074,Business and Pmfessiore Code:The Contractors License Law
does not apply to an owner of property who builds or improves thereon,and _
who doessuch work himself or through hisown employees,provided that such OCC.CROUP IFFS.UNITS
Improvements are not intended or offered for Ole.If,howeveq the building or TOTAL:
i provemw
ont fasold within one yearofcompletlon,the oner-builderwill have -
ER
t16Ldeo of pmving that he did not build or Improve for purpose ofsak.). QTY. Vit ', PLUMBING,PMIT••':ti' tFEE::' FLOODZANE APN
u 1,ae owner of the property,am exclusively contracting with licensed PERMRISSUANCE
contractors to construct the project(Sec.70K Buslness and Professloru Code:
The Comets or's License Law does not apply to an owner of property,who -
Wilds or Improves thereon, and who contracts fou such p7ojechi with a ALTER-DRAIN&VENT-WATER(EA)
,Rt�actor(s)homsed pursuant to the Contractor's License Law. •! ' •FEE SUMMARY
^ 151 am exempt under Sec. B &P C for this reason BACKFLOW PROTECT.DEVICE -
Owner - - DRAINSFLOOR.ROOF,AREA,COND. SANITARY. Y NE
M - Date . =
WORKMAN COMPENSATION ON DECLARATION
711 hereby af(Irma certlR'tha[I have a nte of consent to self-Insur FE(TURES PER TRAP SCHOOL TAX Y_-RECEIPTN
e,ore RECEIPT M
38M,UbC.J Worken'Comperuatlonlruuranceora certlfkd copythereof(Sec. GAS EA.SYSTEM-1 INCA
PARK1ER Y_,N_
Policy GAS G.SYSTEM-OVER4(FA) RECEIPTIf
Com any - BUILDING DIVISION FEE
IBed copy V hereby furnished. - GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
ertifled copy le filed with the city ln+pectlon divl.lon. ^
CERTIFICATE OF FXEMPfION FROM WORKERS' GREASE7RAP PAID L
COMPENSATION INSURANCE •, SEWER-SANITARY-STORM EA.2001+1'. Date ReC l t#-
Qhm lecilon need not be completed If the permit is forone hundred dollars '
($1 Im mile that
- - WATER HEATER W/VENT/ELECTR - ENERGY FEE Y N
Imrtify that In the performance o(the work forwhlch this permit Is Issued, •
I shall not employ say person in any manner so as to become subject to the WATER SYSTIMiTRTATTNG
Workers'Compensation Iowa of California.Date -` PAID
O Z Applicant NEW RESIDENTIAL.PLMB. :OF1'. Date Re0.i t#
Z 0 NOTICETOAPPL)rd to If,
ori making en Certificate o icons oft
of eLyou
snce,youould ma eurthwit co workst cbmpevatmdpmvbis permit
Labor TOTAL: '
CCN Code,you mu,t forthwith comply with each provlsloru or this pemNt shall beGf
W > deemed revoked. BUIL ING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE O
a G Ihereby affirm that there is a construction lending agency for the perform,
Z escort the work for which this permit Is Issued(Sec.3097,Civ.C.)- TOTAL: ELECTRICFEE
U Q ].ender
LL I- L nder,Addre.. qrv. MECHANICAL PERMIT, ' FEE 1. MECHANICAL FEE
U I mmlythat l have read this application and state thattheabove Information
O W ismrmd.Iagree tocomply with all city and county ordinance.and gate lam PERMITiSSUANCA FEES PAID:
} C relating tobullding construction,and hereby authodze representatives ofthLi
H city to enter upon the ae.bove-nealioned property for impaction purposes ALTER OR ADD TO MUCH.
U)
_ (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Recef t#
against liabilities,judgments,costs and expenses which may In anywayacaue AIR HANDLING UNIT(TO 10,000 CFM) - SUBTOTAL:
aga Wtsaid City In cors gmeceof the granting of this Permit.
2 i AIRHANDLTNG UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
igrutum of Applinnt/Coatradot Date EXHAUST HOOD(W/DUCT) CONSTRUCTION•TAX PAID: ,
HAZAR DOUS MATER IALS DISCLOSE R E _
Will the a ppllcant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date - - RCCC t
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the'
Health and Safety Code Section 25532(a)7 - HEATING UMT(OVER 100,000 BTU) TO
F-1YesI_I No - -
Willtheappliczntorfuture building occupant use equipment ordevims- VENTILATION FAN(SINGL.E RESID) - s ISSUANCE DATE
whichemit hanrdous air comaminareas defined bythe Bay Area Air -
'� Quality Management District? B0ILER-COMPOHPORI00,000BTIn
4 Yes [—]No
have read the bars ouss materials requirements under Chapter 8.95rf BOILER-COMP(OVEt 100,000 BTU) p D
the Ca lifornla health&SareCode,Sections 25505,75533 and 25534.7 t'9
understand that ilthe tify the
ing doesoccupant notof currentlyrequir havewhichl,that it bey NEW RESIDENTIAL MCCIq. SQ.IT
respoiuibility to Wuancendify nifi to of =pancqulrcmenls which must be met -
' prior to issuance ora Certificate ofOmpancy. 6® 16 �p�ast
Owner or authorized agent Dare ISSUED DIi f a7t�
TOTAL:
OFFICE COPY
ti