23233 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building d @;�.L0 �s 23233
2
Owner's ante: �� hyipe; A
a 1�.N CITY OF CUPERTT0.
NBUILDING DIVISION
N ^el7 =N APPLICATION / PERMIT
��[•� BUILDING-ELECTRICALPLUMBING-MECMNICAL CATEGORY CO CA
Co
Architect/Engineer. Lk.N.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFOr
Address:' PERMIT ISSUANCE _
LICENSED CONTRACTOR'S DECLARATION
Ihercection affirm 70M)o Div Rcensed 3 oftheerprwlsions ofed Pre Cha
ssion.9de,and e.y PANEL APPLIANCES-RESIDENTIAL JOBD IO
Ingweh I.fid]
force
of Division .fila@Budne@@and ProfessLnsCode,and my
license Isla. (onx end effect.
PANELS Jri'�. �V V
License Chen LILY " c
Date Contractor T�'`\[nst,� F!"%sa—
ARCHITECTS DECLARATION 701-1000 AMPS
reO Zp I understand my plane@hall be used ss public records. OVER1000AMPS SQ.IT.FLOOR AREA S/SQ.FT.
E Licensed PnefessWwl SIGNS ELECTRICAL
Gin t OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MIST
7t, � Ihereby affirm that l ace exempt incentive Contracture License law for the
pO following reason.(Section 7031,5,Business and Professions Code:Any city or
O Z. TEMP.METER OR POLE INST.
Pub countywhich requires apermit to construct,alter,improve,demolInh,or repair
anystmmmprlortoltshwance,ahorequlrestheappliantforsuchpermltm POWER DEVICES
O file a signed statement that he is licensed pursuant to the provlslmes of the
1 to Contractors License law(Chapu r 9(commencing with Section 7000)of Devl-
�0 slon3ofthe Budnusand ProfemlomCdde)orthathelsemmptthercfmmand SWIMMING POOL ELECTRIC VALUATION Q Q
the basis for the alleged exemption. Any violation of Section 70315 by any O e DO
04
.pp Ecart(ora perutsubjectethe applicant to a civil penalty of not more than -ETSSWI'PC FIXTURES
n fIv cited dollars($500). NE ESID AL ELECTR FT.
J144our of the property,or my employees with wages as their sole SQ' STORIES TYPECONSTRUCTION
cepensatlon,wdI do the work,and the structure isnot intended or offered for
O le(Sce 7014,Business and Pro(cssiou Code:The Contractors Lt..Iaw
. $ does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RIS.UNITS
who doessuchworkhternu f orthrough hlaownemployces,provided thatsetch
improvements are not Intended oroffered for sale.If,however,thebuilding or T
Improvement is@oid Mthlnoneyearo(compl&iogtheowner-b°Ilderwlll have
t119Ilirden°(proving that he did nIN build or Improve for purpose of sale.). QTY, PLUMB P MIT FEEPLoo ZINE APN
LJ L as owner of the property,am exclusively contracting with Ilcenaed PERMIT CE. /
contractors to construct the project(Sec.7014,Business and Professions Code:
The Cm Icaderb License law does net apply to an owner of properly whopL'IER.DRAM& -WA (EA) ��
builds or Improves thereon, and who common, for such p(ojects with a PEE SUMMARY
cgn[Iactor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT. CC /+
LJ I am exempt under Sec B&P C for this masonOwner DRAINS FTAOR ROOF,AAEA, ND. sANRARY Y N—
Date RECNPT Y
�l WORKMAN COMPENSATION DECLARATION , , SC1300L TA% Y— N
„sal hereby affirm cePER rtificate that I have a of consent to self.Insure,or RECEIPTNM
c difiateofWorkers Compematl°nlmuranmoraartifiedmpythereof(Sec. GAS EA.SYSTEM-IWGOUTLETS
3300,1ab C3 PARK FEE V— N
Policy Y RECEIPT x
Cam an GAS EA.SYSTEM-OVER 4(EA)
Y BUILDING DIVISION FEES
i Centfled copy In hereby fhthe city CREASE/INDUSTRL WASTE INTERCEPTOR PLANC14ECKFEE Icy
Certified ropy In Ned with the city Inspection division. 1
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Thlsscctio°need net becompleted lithe permit Informer hundred dolhSEWER-SANITARY-STORM STORM EA.2DOFT Date Rcoel tp
($1I adilesa.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
.Ill not that o any personhe In n tmannerhe so as to become
pesubjecrmit Is�o theol, —
�� I shall not employ any person In any manner so u to bemrre subject to the WATER SYSTEM/TREATING PAID
Workcn'Compcnatlon Gwa of Call(omia. -
O Date Z NOT[CntcoNEW RESIDENTIAL PLMB._SQFf. Date Recel till
Z O ODCE TO APPLICANT:If,after making this Certificate of Exemption,you
should beme subject to the Workeri Competent ion provisions of the Labor TOT
0IrCode,you must forthwith comply with@uch provisions or this pernetshall be
y deemed rev.ked. BUILDING
a0 CONSTRUCTION LENDING AGENCY - SEISMIC FEE
I hereby affirm that there In a ceuwctlon leadleg agency for the perfor ELECTRIC FEE
M Z and ofthe workferwhlch this permit In te.ed(re.3097,Cie.C.) TO
U O lenders None PLUMBING FEE
IL L..der.Addmss QTY. MECHANICAL PERMIT FEE' MECHANICAL FEE
O W Icertlfy thatl have read thhappliaBonamisetethattheabovelefomeit -
Ismrmct.I agree to complywith all cityand countymdleances and pate laws PERMITISSUANCE PEES PAID:
1 retailing to building construction,and herebyauthorterepresentnOveso(this
F Z city to enter upon the abovearentloned property for inspection purposes. ALTERORADDIOMECH. a
(We)agree to save,indemnify an d keep harmless the City of Cupertino Date ReeeiFtll
V agalutllabl dgerents,costs and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agminate sequence of the granting of this permit.
AIR HANDLING UNIT(DYER 10,000 CFM) CONSTRUCTION TAX
sl p / racior Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant store or handle haoardous HEA77NG UNIT(TO 1 W,0D0 BTU) Date Da
material as defi reed by the Cupertino Municipal Code,Chapter 9.12 and the RCCeI f
Flaalth and Safety Coder.-S�ection 75532(a)7 HEATING UNIT(OVER 100,.00 BTU) TOT
nYea u No
Will theappllmnt or futumbuildingoccupacct uaeequlpmentor devices VENTILATION FAN(SINGI.E RESID) ISSUANCE DATE
which emit haearelous air contaminants as defined by the Bay Area Air —
alityManagementDistrlct7 BOILER-COMP QHPOR 100,000 BTU) PAID
Vea g❑No
Tv haven readthehanrdoUs materials requirements underChapter6.95 of BOILER.COMP(OVER 100,0!0 BTU)
:he California Health&Safety Code,Sections 25505,2SS33 and 25534, 1
that notify
the occupant noterequirmats which
that Rhmy NEW RESIDENTIAL METH. SQ.FT FEB 19i�
responsibilityortoIssuance
c not ifytheic to of of the rcqulrcments which must be met
prior to Lasuance o(a Certificate o(Occvpanry.
Vit
Owner oramhorlud agent
Data ISSUEDB ✓
TOTAL JJYVV/
OFFICE COPY