23021 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildingProtect Identification PERMITNO,
Building Addreo 23021
woers .mea one:
CITY OF CUPERTINO-BUILDING DIVISION
Ccctor'sName:1 ` 2 sae.j; APPLICATION /PERMIT
N BUILDING-ELECTMCAL-PLUMBINGMECHAMCAL CATEGORY CO
Arthisct//.E,nng'loeer. Llc.No:
s�1rn �LTY� ' BUILDING PERMIT INFO
QrY` ELECTRIC PERMIT ' FEE
Add.:
PERMITISSUANCE
LIGF.NSED t[amCONTRACTOR'SHeunderrDECLARATION
I hthSyi.irmthatlam,1.3.f underpros.rul....mf.i...0(damn AITUANCFSRESIDEMTAL JOB DESCRR'fION
Inge is
lull 7000)o(d citeon3c(the Buslnmsand ProlemioneCode,and my
IZZ Is in full fo and c.#' �, ` ( PANELS $r
LlcenxC m Contractor
� `N�
Date 1 p/)_ Contractor,��_ 1'.�,ry'
Jy ARCHITECT ON OVERWAMPS
0 O I understand my plans shall be used m puhllc remMs OVER 1000 AMPS SQ.Ff.FLOOR AREA 'S/SQ.FT.
(❑� Limnxd Professional SIGNS ELECTRICAL 2 t,.��-k Z�c
GGG leu OWNER-BUILDER DECLARATION •J
{ten Cil SI'ECIALCEtCUIT/MISC
2F, .7i ovinghereby aRfrmthztlam exemptfromlhe Contractor's License Law fort he
oo following reason.(Section 7 t to mtmd and Professions Code:Any city it
O Z t.� TEMP.METER OR POLE INST.
F� mantywhich requlreaa permittomrotmct,alteylmprove,demolbh,orrcpalr
S anystmcture prineto its issuance,alsorequireathe applicant fmsuch permit to POWER DEVICES
t-` Rle a signed statement that he is licensed pursuant to the provisions of the -
Q6 3 u, Cco acts/s License Law(Chapter 9(mmmercmg with Section 7000)of Divi- SWIMMING POOL ELECTRIC
eion3 otthe Business and Profemlo sCode)orthat he is exempt there(romand VALUATION
g the basis for the alleged exemption. Any violation of Section 7031.5 by a^ am
OUTLETSSWITCHFSHXTTJRFS
Oas appilcant(ore permitsubjectsthcepplicanttoa civil penalty of not morelhan g9
$ five hundred dollars($500), NEW RCSl pl ELECTR
I as owner of the property, SQ.FT• STOR165 TYPE CONSTRUCTION
�n p perry,or my employes with wages as their sole
comp,.704,willdothe work a a s1c,.Code:The C intended or of( c Law
O sets(Sec.7070,Buam.and I'm(embro Code:The Contractels Llmme law
�5$ does not apply to an owner of property who build.or improves thereon,and OCC,GROUP __WFS.UNITS
who doessuchwork himself orthreugh hisownemployees,provided that such 19
improvementsam not intended oroffered forsale.If,however,thebulldi^g or TOW.
improvement tssold within oneyearofcompletb theowner-bullderwill have
thrQ*rden of proving that he did not build or improve for purpose of sale.). QTY IN MIT FEE FLOO wNNE APN
U 4 as owner of the property,am exclusively=trading with licensed
contractom tommimctthe project(Sec.7017,Businem ami Profemlam Code: 1 PERMIT LSSU ��.
The Contmctore License Law don not apply to an owner of property who ALTER-DRAIN TER tEN
builds or Improves thereon, and who contracts fee such plojects with a _
cactor(.)licensed pursuant to the Contractors License Law. BACK FLOW pgOTECT.D FEE SUMMARY.
c61 am exempt under Sec B&P C for this mason
OUTSI DF FEES
Owner Data
DRAINSFLOOA ROOF,A M COND. SANITARY Y_ N
WORKMAN COMPENSATION DECLARATION RECEE T 0
� ❑I hereby affirm that I have a mrtificate of consent to self-Insure,ora FIXNNFS PER TRAP SQi00L TAX Y_ N
certificate of Workers Compensation Insurance or a cartlfled copy thereof(Sec. RECEIPT#
380,Lab C.) GAS F.A.SYSTEM-]INCAOUTLFTS PARK FEE Y_ N
Policy# GAS EA.SYSTEM-OVER d(EA) RECEPT p
^Y BUILDING DIVISION FB ES
rtified ropy b hercbyth the cityuef. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCI-IGCK FEE �� tg lag
Certified espy ts filed with the dry inspection division. —1,J
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWERSANITARYSTORM FA 200FT Date RCM( t I ^_
(This section need not be completed lithe permit ts m - -
(carohundred tlolla _
($10()mlem.) WATFRHFATERW/VENT/ELECTR EN F Y N
I ntrif(y that In the performanca^(the work forwhich this penult ishw _
I shall not employ any person In any manner so as to become subject to th WATER SYSTEM/TREATING
Workers Compensation laws of California. Date PAI
C' Z Applitant Dat Recei t#
Z NEW RESIDENTIAL PLMB. IT.
O shoulNOTTCE70MPLICANT:$eherrmHompar ation Paleof Exem)etioryyo c"Q '
W Code,you
must ubpnmthe Workers Comperoisions orchis permits Lab / FO-fA
Code,you meet forthwith comply with such provision orchis permit shall b
� j seeress revoked.
BUI
ag CONSTRUCTION LENDING AGENCY SEI C FEE
I hereby affimn slut there b a construction lending agency for the parlor ELECTRIC.FEE
Z ansa of the workfor which this permit I.Issued(Sec.3097,Civ.C.) TOT
V O Tendcea Name PLUMBING FEE" s - s
LL — Isnaer's Addrem 'Y. MECHANICALPERMIT ..",FEE MECHANICAL FE
O W I certifythatl have read thisappllcatlonand statothatthe above lnformatlon '
1 Iscovect.I agree to comply with all city and countyoNinanmsand stale laws I'FRMTTISSUANCE ` �� FEES PAID:
} N rel Ing mrotructlon,and hereby euthorlao representatives of this '
Z to.mercapto the above-rrcntlomM pertyfor Wpectionpurposea, ALTER OR ADD TO MECH. Date BCCI t#
_ (We)agOfu
ndemnl(y r e t 'ty o(Cupert(oo
agairot Babenh,rn ex nx nanywayamue AIR HANDLING UMT(TO 10,030CIM) S TOTALag.mossidILAIRHANDLING UNIT(OVER 10,M0CIM) CONSTRUCTION X
u otractorDateEXHAUST HOOD(W/DUCT) CONSTRUCTION X PAID:
RDOUS MATERIALS DISCLOSUREIt cture building occupant store or handle havrdous HEATING UNIT(TO 100,000 BTU) —
ma as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date Col
I 1 and Safety Code�Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) T L
Yea L_I No
Will lhezppllcant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ` ISSUANCE DATE
which cont haasrdous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP Ow'OR 100,000 BTU) -
Ye. ❑No ^
have madIkalth the &Safety Cade,Se requirements underChapter 25534. 15 of BORER-COMP(OVER 10,000 BTU) PAID the Glifamla}[ealth&Safety Code,Sections 75505,25533 arid 25534. I
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.
responsibility in notify the occupant of the requirements which mu at be met y_` : 1/I� O�
priorm lssuance ofa Certificate of Occupa^ry. N„
A ams ��i
Ownerorauthotludagent Date " _ `
aA / TO I ISSUEDBY: -
OFFICE COPY