23906 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Bu to Address: pq N , 1 23906
nor arse: one:
a ' APPMCXT!577U9WTr1`AT:=A
OF CUPERTINO-BUILDING DIVISION
con OName:r's Ic, o:I APPLICATION /PERMIT 4
BUILDING-MMTMCALPLUMBINGMECHAMCAL CATEGORY CONTROL#
Artful.ct/Engineer. Ic. o.
E BUILDING PERMIT INFO
ELECTRIC PERMIT
A • `'I PERAIITISSUANCt / ❑ ❑
L LENSED CONT ACTOR'S DECLARATION
I herebyafflrrothat l am licensed under provisions of Chapter9(conomme APPLLANCESRFADEkPai, IDB DESCRII'I30N
E%wrth Sembn7000)of Dlvision3olthe Busloessand ProfesslonsCode,and m
Ii.mx Is InfuUVXandeffect. I[ / �/1 PANELS A�
License Co.X L •� O
Date Contractor
ARCHITECPS DGCLARATION I A.MIS
ail ZOO I understand my plans shall be used as public records. IOW AMPS SQ.FI.FLOOR AREA $/SQ.Fr.
U Ltcar dProfessional SIGNB ELECTRICAL
6 r4r�7 OWNER-BUILDER DECLARATION
Ina SPECIALCIRCUIT/MI
Ep'vlI hereby afRrmthat I am exempt from the Commuter's LicenseLaw for the
ZOZ following rcason.(Sectim,7031S,Busheseand Pmfesslms Code:Anytltycr TpMp METER OR POLE INST. `•�'
F F countywhich requires a permit toconstmct,alter,Improve,dennlish,ormpalr
�� a any structure priento its Iseuance,also requimthe applicant for such permit to POWER DEVICES
ryG U file a signed statement that he b Bernard pursuant to the provisions of the
Owl
Contactor.License Law(Chapter 9(commencing with Section 7000)of Divi-
� S slon3Ofthe Budnesaandexemption. Any)violation f evempt therefrom and SWIMMING POOL ELECTRIC /� VALUATION,r41G
O the basis for the alleged exemption. Any violation of ealt 0 rot m by any OUTLE38SWITCHESEKTURES So�Q V/
applicant fora permit aubje[eche applicant to a tivll pemky M not morcthan V
Q
five hundred dollars hepr.
- NEW RESIDENTIAL ELECTR
❑I,ssowner of theproperty,or my employeeswithwagesr[herrsole `"Q'hT' STORIES TYPE CONSTRUCTION
compensation,will do the work,and the structureoeTh era Intended o iofferedfor
O doe(See.7044,outaply to an
nowerf property who
Contractors License Law
$ does not apply to an owner or property who builds or Improves thereon,and
r- who does euchwork himself orthrough hbownemployees,provided that such OCC.CROUP RF.[1M'TS
improvements are not Intended oroffered formic.If,however,thebullding or �...�
Improvement bsold withinoneyearorcompletion,the owner-bulWerwlll have
tIE.Ifurden of proving that he did net build or 4npmve for purpose of sale.). QTY- PLUMBING PERMIT FEEP.T-OpDypNE APN
L as owner of the property,am exchrmvely contracting with Bernard PERMIT ISSUANCE
rontracton to corotmd the project(Seo 7014,Bsi
uness and Professkma Cde:
o
The Contraeor'a License Law does net apply to an owner of property who pL3FR-DRAIN kVENT-WATER(EA)
Wllcis or Improve thereon,and who,contracb for such pRoM jewith a
ro6actor(s)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY'.
L1 I am exempt under Sec. B k P C for this reason
OUTSIDE IT
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
i� Owner Date RECEI'I#
1
WORKMAN COMPENSATION DECLARATION FIX.NRFS PER TRAP SCHOOL FAX Y N
❑LM1ercby affirm that I have o cl rt erne of consent to sull-finsure,ora RECRUIT#
artl0abC.Warken'Comperuatlonlnaurana araanBied copythemo((Sec, GAS EA SYS'FEMI ING4 OUTLETS 38 W,lab CJ PARK FEE V_ N
I olky IF GAS EA.SYSTEM-OVER 4(EA) DING DI N
Com any BUILDING DIVISION FEES
ECcelifled copy is heed with necity CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
❑Certified copy b filed with the tlty Inspection division'
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
INSURANCE
NSURANCE
(fM1bstolonneed not be COMPENSATION
if Nthe permit bforone hundred dollars SEWER-SANITARY-STORM EA 200F17Date RCCeI t#
($IW)or rasa.) WATER HEATER W/VENT/E[FGTR ENERGY FEE Y N
I certify that in the performance of the work forwhich this permit is Issued, —
I shall not employ any person In any manner so as to become subject to the WATER SYSfhM/TRGTINC
Workers'Compensation Laws of California.Date PAID
0 Z Applicant Date Recei t#
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLME. SQFT.
should become subject to the Worker Compensation provisions of the Labor TOTAL:
V) Code,you moat forthwith complywith such provlsrorsurthis permit shall be
> deemed revoked. BUILDING FEE
dG CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirthat there h a construction lending agency for the perform
Z arc,of the workfm or which this permit is Issued(See.3097,Civ.C.) TOTAL: ELECTRIC FEE
U O <^aero Name PLUMBING FEE
IL I— Lcuder'c Addreaa QTY. MECHANICAL'PERMIT FEE MECHANICAL FEE
OW 1 certifythati have read this appllationand elate that theabove tefarmmron
1 iscomect.I agmeto comply with all eltyand county ordinances and mate laws PERMIT ISSUANCE FEES PAID:
>. W relating to building mnatrudlon,and hereby authorize representatives of this
H Z citytoenteruponthe m fo Ig Ion purpose. ALTER OR ADD TO MECH. Date ReCej [#
— (We)a ass the City or Cupertino
agal nt useewhlchmaylnanywayacenus AIR HANDLING(IMT ITO to,"CFM) SUBTOTAL:
ce err the gra n permit. w AIR HANDLING UNIT'(OVER 10,0D0 CFMI CONSTRUCTION TAX
Date IXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
77AZARD0 MATERIALS DISCLOSURE
Will theapplicaut orfotvre building occupant store or handle hazaMous HEATING UNIT(TO 100,DDO BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the __ Date Rout I#
Ifcelthand Safety Code Setl1on25532(47 HEATING UNIT(OVER 100,000 BTU) - TOTA
1�] Yes M No
TNlliiheapplicantorfutumbuildingocaupantuseequipmentordevlces VENDLATION FAN(SINGLE RESID) ISSU CE DATE
which emit hazardous air consentutnts as defined by the Bay Area Air p
- Quality Management District? BOILER-COMP DRPOR 100,000 BW
MMM111
4 Yes 4 No . p1
have read the haze ous materials requirements under Chapter6.95 of BOILER-COMP(OVER 100,000 BTU) 'JU,tl 29
the Clllfensu mice Health building the Safety Codc,SMlorre 25505,ve a t and nan,that.1 ���y_
ustpntandthat notifytheoctlon of t e rrentlyhavea tenant that it boy NEW RESIDENTIAL METH. SQ.Ff. J(UI/�✓/\J
priors Islability Issuance
notify occupant Oftherequirements which mum be melt C+1Y Ur
prior m Issuance of a CertiflatO of Ompanry. 1 I+Uf Cfy t U
Owner or authorized agent -' Date ISSUED By��
TOTAL:
OFFICE COPY