23664 APPLICANT.TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PERMIT NO.
ZZ
Building Ao,,:lip �. �. �� 23664
Owns
Phone: rmwr=
1__3?;6& CITY OF CUPERTINO-BUILDING DIVISION
Cont, or� �, LyN,n� ' APPLICATION / PERMIT j sate BLITLDINGELEC7RICALPLUMBING-MECFUMCAL CATEGORY CONTROLp
Arc act glneer: Lk.Na:
QTY ELECTRICPERMIT FEE BUILDING PERMtTINFO-
Address: - PERMIT ISSUANCE ❑ ❑. �j ❑
LICENS EDCONTR under provisions
L�]I
[hereby dBrm that 0MDivlkrnsefth.Hu e .aldP iahapter9(mmmrnc APPLIANCESRESIDENRTALing - JOB DISCRB'I'ION
nor ..hSectionJame of Division (the Buslvemand ProlesslonsCode,end my
license le 1.fun and effecl. ,7 f PANELS y 1
License Clam LIC.# J
Date ,9 J� Contraam
ARCHITECTS DECLARATION 701-1000 AMI5 G4�iv
ZO
❑❑ I understand my plan,sW 11 W used m records.rds. OVER IWEI AMPS SQ.FT.FLOOR AREA
`j Licensed Professional SIGNS ELECTRICAL -
<�G OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC
Ihereby afflrmthat l am exempt from the Contractor's License law for the
ZO 2 following mman.(Section 7031.5,Business and Professions Code:Any city or TEMP,METER OR POLE INSr.
K F' c ntywhk rNubeaapermlttomnstmM, ter,Impmve,d..IWh,ormpalr
any.tm=m prlorm its bseance,alsorequiresthe applicant for ouch permit to
file a signed statement that he Is licensed pumuant to the provl,low of the POWER DEVICES
On. Contractor's Llcerea Law(Chapter9(mmmencingwith Section 7(XD)ofDivi-
111OS sum3ofthe Buelnessand Pmfessiusa Code)mthat hats exempttherefromand SWIMMING IDOL ELECTRIC VALUATION
6 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWI I•TXT'1112F5
p appBenotfora permit subjects the applicant to a civil penalty of not more than --
Q five hundred doll (¢00). - b
ars NEW RESID AL ELECTR SQ.Fr. _ �STORIES TYPE CONSTRUCTION
p,
I]1,as owner of the pmperq,or my employees with wages as their sole
pematicowindothe work and thestructure bnotlntendedor offered for
Dsale(Sac.70K B..auu and Profession,Code:The Contractors Lt..law
$ does not apply to an owner of properly who builds or improves thereon,and OCC. ROUP . RFS.UNITS
who does such work himxlforthro ugh his own employee,,provided that such
improvements are not intended proffered for sale.](however,thebullding or /y'I
bnpmveamm essold within onpyearofcomplelbn,theowner-bullderwlll have --- mj J
[ ndenofprovingthathedld can build or improve for purpose of sale.). QTY, . PLUMBING PERMIT FEE FLOG ZONNF. MIN
�1,as owner of the property,am exclusively counseling with licensed pERMITISSUANCE /
contrscton to mt,tmd the project(Sec.7076,Business and Profession,Code: N
The Contractor's License law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon,and who contracts for such p(ojects with a
roptradurfs)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
I_l I am exempt under Sec. B&P C for this mown
DRAINS FLOG ROOF, SANITARY Y N
• OUTSIUIHITS
Owner ' Date - R AREA,GOND.
WORKMAN COMPENSATIONRECEPTN DECLARATION FC(TURES PER TRAP SCHOOLTAX Y N
I hereby affirm that I have o rertlBrate of.consent to copy
ora RECEIPT N
ceoo U1eofWorken'Compewatlonlmennce ora certified ropy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLm PARKER Y N
3800,Tab CJ ../�
Paltry p � L - ' DING DIVISION
p
Com env a i. CAS G.SYSITR.T-0VER4(EA)
y iy BUILDING pI VISION FEEB
ICartW dropy ban uMshed. + CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
CedlEed espy b filed with the city W)eMlon division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
xCOMPENSATIONINSURANCE SEWER-SANITARY-STORM EA 20 Date Recei t#
(Ihlsctlon need nb completed ted permit b Corona hundred dollars
WATER HEATER W/VENT/ELGCTR ENERGY FEE Y N
Icertify that in the perfomsomofthe work forwhich this penult is blued, .�O —
I,hall not employ any person In any manner n ase.Demme subject to the WATER SYSTCM/TREATING
Workers Compensation Lawsof California. Data PAID
0 Z Applicant
Z O NOTICE TO APPLICANT.I(,act making this Cadifkateof Exemption,you NEW RESIDENTIAL PLMB. SQ.Fr. Date Reeei I#
Hshould become subject to the Workers'Compeasation provisions ofthe Labor TOTAL:
fA Code,you=a,forthwith comply with such provisions orthb permit shall be
> deemed revoked. BUILDING
1 G CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby afflmrthat there Is a construction lending agency for ted perform- ELECTRIC FEE
Z ancoftheworkforwhichthispermitbbsued(Sec.3097,CIv,C.) TOTAL:
(� O Lradcra Name PLUMBINGFEE
LLI— LenderaAddmm QTY. MECHANICAL PERMIT','. FEE MECHANICAL FEE
O W Imfleythat l have mad thbapplintlon and matethatthe above Inform tion
IL bcomed.Iagreem<omplywith aB cityand rountyordinance,and,tate laws PFRMITISSUANCE FEESPAID: .
>. relating to building construction,and hereby authorize representatives ofthls
F city to enter upon the above-mantloned Properly for Inspection purposes. ALTER OR ADDTOMECH.
U)
(We)agate to save,indemnlly an d keep harmless the City of Cupertino Date Receipt#
V against liabilities,judgments,cogs and expenses which may In anyway accrue AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL
agzl Bald City k rons�e y the gnnbng of thls parmit.
AIR HANDLING UNIT(OVER In000CFM) CONSTRUCTION TAX
4
Si lure of Applicant Contractor Data EXHAUST 110013(W/DUC'D CONSTRUCTION TAX PAID:
HA7ARDOLS MATERIALS DISCLOSURE
Will the applicantor theurcrtino building occipan ode, hhandle hazardous HEATING UMT(TO 100,O30 BTU) Date Recl I#
Helldal as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the
Health and Safety Code Section 75537(x)7 ]-[EATING UNIT(OVER 100,000 BTU) TO
(-1 Yes r]No
111 the appllcanlorfuture
c..tm;.otgoa eflard y equipment Aron devices VENTILATION FAN(SINGLE RESIW ISSI�'A&(;EL)ATE
which eMahazardoussirrict? sant,ae defined by the Bay Arca Air
Quality Management Dlaldct7 BOILER-COMP DEEP OR 100,IX10 BTU)
4 Ys �No /1 ���
have nod Health
sus No.
Se requirements2550underChapter2S53rli.95 of BO➢.ER-COMP(OVF➢21fA,OfA BTU) p�
the Califomb Health&Salary Code,Section,25505,25533 and 75536.I
undenta rad that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.Fr. CII Y-Vf
responsibility ssue ce notify Ce reompantmupancquircmnte which must be met 1x41'Cfil _,f`
priortoissuanre oiy the occupant
ocof he req
y.
Owner or authorized agent Date
TOTAL: ISSUED BY:
OFFICE COPY