23008-Wilson Park APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: �D� . `e� [INS ��_ 23008^O O 8
nere ante: f7� V one. �lyb�'L'�N1 G l'.l( 1�.{7
Q�
COP ISMN4_� CITY OF CUPERTINO-BUILDING DIVISION
Contractor's Name: // Lic.No, APPLICATION / PERMIT
1 E Gcnr_re_k_ n uC'FI�YI 44o BU)LDING-ELECTRICAL-PLUMBING-MBCFIANICAL CATEGORY CO 7
Architect/Engineer, Lic.Na.
- .¢ii' C' ;EGEC`TRIC PERMIT• • FEE' ` 9 BUILDING PERMIT,INFO
Address: - PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that lam licensed under provisions of Chapter 9(commeno. APPLIANCES-RESIDENTIAL JOB DFSCRR'TION
ingwith Section 7000)of Division 3 ofthe Bustnessand ProfessionsCode,and my
license is in full force and died. PANELS Ywa, a/'
License Class Liatl ��V Va"��`7
Data Contractor UP TO 200 AMPS
ARCHITECTS DECLARATION 201-1000 AMPS
NZ I undcistand my plans shall be used as public records. OVER IWO AMPS SQ.FT.FLOOR AREA $/SQ.FT.
CO
Licensed Professional SIGNSELECTRICAL
4 m OWNER-BUILDER DECLARATION D ' A,
In Id SPECIAL CR(GUIT/MISC ,v
t y., I herebyaffirmthatI an,exempt from the Contractors License Law forthe
�'ZO_ following reason.(Section 7031.5,Business and Professions Code:Any city or `
O'Z H TEMP.METER ORPOLE INST. H
countywhich requires.permitrocorutruct,altepimprove,demolish,orreper
q� F" JTP
�t �a any structure prlorwits Issuance,also requirestheapplicant forsuch permit to POWER DEVICES
K o V file n signed statement the he Ia licensed pursuant to the provisions of the
3pG Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
sion3cfthe B.xbuasand Professions Code)orthat he is exempt therefromand V DATION
0 5 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHEAFIXTURES
666 applicant for a permit subjects the applicant to a civil penalty of not mare than
five hundred dollars($500). NEW RESIDENTIAL ELECTR Fz° SQ.FT. STORIES TYPE CONSTRUCTION�n ❑I,as owner of the property,or my employees with wages as their sole
compensation,will do the work and the strucWre Is not,intended or offered for
S ❑ sale(Sec.7094,Buslne..and Professions Code:The Contractor's Lierme Law
t$g$ does nM.pply to an owner of properly who Wilds or Improves thereon,and OCC.GROUP 11 RIS.UNITS
0.0. who doessuch work himself or through hlsown employees,provided that such
Improvement.are not Intended or offered for sale.If,however,the building or TOTAL:
improvement is sold within oneyearofcompletion,the owner-builderwiil have '
Ole�karen of in that he did not build or Improve for purpose ofake). pEUMRING PERMIT ' t.':�•'FEE
LJ Prov 8 P ting QTYI.:o•, FLOOD ZINE APN
L a.owner of the property,am.7044,Business
contracting with licensedcorPERMIT ISSUANCE
The Co tra o constructtheLawproject(Sec,apply to an sand of Tonper Code:
The Contractors s.the Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds t r improves thereon, and who contracts for such pto)ects with a
co,tRTactor(eexem licensed
pursuant Sm. the Contractor's License Law. BACK FLOW PROTECT.DEVICE ..t 'FOUSUMMARY•'
L�I am exempt under Sm. B&P C for this mason
DRAINS FLOOR NTI.ROOF,AREA,COSANITARY Y N
TSIDE FEES
Owner Date - RECEIPT p
WORKMAN COMPENSATION DECLARATION PER TRAP SCI{(3OL TAX Y_ N
E31 hereby affirm FIXTURES-that I have a certificate of consent to self-Insure,or RECEIPT
certificate ofWorkeri mm
Compeattonlnsurance or a certified copytheof(Sec.
3800,Lab C.) GAS EA.SYSTEM-11NC.40[TfLETS PARK FEE Y N
,
Policy p MGAS PA. BUILDING DIVISION FEES 4(EA) RECEIPT N
Com any -CekiRedcopylsherebytuml.hed. G
' ❑Certified copy b(iced with the cityIrrtpectlon division. REASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF IXWPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCESEWER-SANITARY-STORM EA.200FT. Date Recei t#
Trhissection need out W completed if the permit tsfor one hundred dollars
($100)rtifytJ WATER HEATER W/VENT./ELECTR ENERGY FEE Y N
I cent that In any pehe rson
In any
th surer work an as to
this permit is k.wed, —
Ishall not employ any pereon In any manner an as to become er to WATER SYSTEM/TREATING
l�� Worksr�Compenaatlon o(GII(omh. Date (dk PAID
O ZJl Appllcall[ NEWRESIDENTIALPLMB. SQ.FT. Date Rewi t#
Z NOTICE If,efterm o(EremptWn,you
sh.ldbr.ne.ubjectt.tha Works Compen.atlo 0,f Ofthe Labor TOTAL:
fA Cade,you must forthwith comply withauch provisions orthis perna shall be B ILDIN •E
W j deemed revoked.
dI hereby efftCONSTRUCTION LENDING AGENCY _ SEISMIC FEE
rm that there 0 a mmtmdion lending agency for the perform- ELECTRIC FEE
D Z ance ofthe workforwhich this permit is lssued(Sm.3097,CIv.C.) TOTAL:
IF
U O Lender'x Name 7 PLUMBING FEE
LL Fe Lenders Addre.a QTY: MECHANICAL;PERMIT ` - FEE MECHANICAL FEE
OW Icertifythat l have read thisapplicationand statethattheaboveinformatlan -
(L Iscorrect.Iagreeto complywith all cityand county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} relating to building construction,and hereby authorize representatives of this
(_ city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
Z Daft ReCet t#
_ (We)agree to save,IndemNfy an d keep harmless the City of Cu pertim p
against liabilities,judgments,costs and expenses which may in any way acme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
ago Inst said City in connector..of the granting of this permit. -
AIRHANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Signatureof Applicant/Contract., ' Date - 6(HAUST HOOD(W/DUCO CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant Or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Daft Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I Inalth and Safety Code Section 25532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes ,I+��I No -
Willtheapplicant or ,Ruhr,building Occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air _
Qua lity Management District? - BOILER-COMP DHP OR 100,000 BTU)
E?Yes M No
•. havercadthehaza Ous materials regWmments under Chapter 6.95 of MOILER-COMP(OVER 1(0,000 BTU)
the Glifomia Health&Safety Code,Sections 25505,25533 and 25534.1
understand that if the building does not currently have a tenant,that it 4 my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to artily the Occupant of the requtrernoda which at be met
prior to Issuance of a Certificate of 0cmpancy. '
Owner or authorlud agent Data ISSUED 6
TOTAL:
OFFICE COPY