23053 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
BuOding Addrcm:
23053
ro o z
tier a+ rr,' �.QQL .
1"CV,�i' CITYOF CUPERTINQ6UILDINC DIVISION
CovtractmhNime: Lie.No: APPLICATION / PERMIT 2
Archils t/Engineer:
BMLDINGELECTRICALPLUMBINGM HAMCAL CATEGORY CONTROLN
Lic.No:
why QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE - ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions ofCMpter9(commere- APPLIANCES-RESIDENTIAL JOB DPSC ION
ingwith Sen1onMW)o(Dtvision3ofthe Businemand ProfessionsC e,and my �
license lain full form and effect. PANELS � /
License Clam Lte,, "' ®wvt�u
Date Ceetranor
ARCHITECTS DECLARATION 1014000 AMPS
Al IunderstandmyplareshanbeuwdupubOcrecordw OVER1000AMPS a IA�a1fOR
ZtoLicensedPro(emlarul SIGNS ELECTRICAL N0G\VVIIa�,Hn, ®LL R
�6� OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC -COMPUT
U T R •
7f, a Thereby a((Irmthatlam exempt(romthe Contractor's License Law for the
following reason.(Section 70315,Business and Professions Code:My city or
H TEMP.METER OR POLE WST.
FE
county whkh rcqulresa permit tocomtronireath aprovgdemolbh,ormitI
any atrocturepnormitaketenes,also Hoduseulresthant to the provisionoresuch of to t
Nd fileCo a signed statement that he h Bcensed pursuant cing it the tion 7000) of the POWER DEVICES
Ok Contractor'susiLicense
.andLaw PhaplerxCoda) thathellh Semptth0W)of Divi.
mand
30 smn3afthe Buelnessend ProtemlomCode)anther he lnexemptthere(romand SWIMMING POOL ELECTRIC VALUATION C�
�.' the Wait;for the alleged exemption. Any violation of Section 70315 by any '1\ Q
p� ppBant(ora permit subjenstheapplicantloa civil penalty ofnot morelhan OUTLETSSW[TCHFSEXTURES �VV _
Q rave yy�ared dollen($500).
' I+. Cpl' NEW RESIDENTIAL ELECTR gQjT,
I,cue owner o!the property,or my employees with wages a their sole STOW LS TYPECONSTRUCTION
z5� er anon,will do the work and the structure b not Intended or offered for
F O sale(See 7061,Business and Profession,Code:The Cortmnors License law
$$ does not apply to an owner of property who builds or Improves thereon,and _ OCC.GROUT' RES.UNITS
who does such work himself or through his own employees,provided that such
Improvements are not intended oroffered for sale.IL however thebulldlnS or TOTA
improvement bsold wlthinoneyearofcomplellogtheowner-builderwlli have
t1VLjvMen of proving that he did not build or Improve for purpose ofmlej. QTY. PLUMBING'PERMIT ' 'FEEFT DWNE MIN
u L as no,of the property,am exclusively mmmcmi;with licensedpp(MRLSSUANCE �.�
contractors to construct the pmjed(Sec 7046,Buslnem and Pro(embm Code:
The Contnnor's License Law does not apply to an owner of property who ALTER-DRAIN&VPM-WATER(5A)
Wilds or Improve thereon,and who contracts for such pipjecls with a
rUractorts)licensed pursuant to the Contractors License Law. SACK FLOW PROTECT.DEVICE FEE SUMMARY
L j I am exempt under See B &P C,for this reason
DRAINS.lDRAINS-FLOOR HOOP,AREA,COND. SANITARY Y N
OUTSIDE
Owner
WORKMAN COMPENSATION DECLARATION
RECEW NARATION FIXTURES.PER I.RAP SCHOOL TAX Y_ N_
01 hereby affirm that I have a certificate of consent to mlf-Inure,ora �� RECETT N
certificate of Worken'Camperuatlon l�uurance ora certified espy thereof(Sec. GAS EA.SYSTEM-1 INCAOl711ETS
3500,Lab Cd PARK FIBS Y_ N
Polity p RECEIPT p
Com an GAS-EA,SYSTEM-OVFR4(EA)
Y BUILDING DIVISION F[ES
titifiCaddied ropy b hereby th the cid. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
❑
Caddied espy E flied with the city Irespenion division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID
COMPENSATION INSURANCE
(Thlssectlooneed net becompletedlfthepormtH isfororiehundred dollars SEWER-SANITARY-STORM EA.20017. Date Recn)pt#
(51 I mdifem3 WATER DATER W/VENT/ELECTR ENERGYFEE Y N
[certify that In any pehe rson
In an thework
an as tooh this becom esmlt cttothissued, -
I shall not employ any person In any manner n m to become subject to the WATER SYSTEM/TREATING
Warkcrs'Compensetlon Laws of California Date PAID '
0 Z Applicant NEW RESIDENTIAL PLMB. SQIr. Date Rccei t#
Z p NOTICE TO APPLICANT:If,elver making this Certificate of Exemption,you
Fshould becamsaubject to the Workars'Compensation provisions of the Labor TOTAL:
N Code,you must forthwith comply with such proWlomorthis permltehall be
j deemed revoked. BUILDING •
CL C CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z
Iherebyaflrmthalthere taacorutmnlon londingagency1mthepef., TO ELECTRIC FEE
an of the work for which this permit is Issued(Sec.3097,Civ.C.)
V O rendes Name PLUMBING FEE
LLI— Lenders Aadrcm QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OWlcedifylhatlhavercadthbappllcatlonandstalelhattheabovelnformation
S Lscorrect.I agree to comply with all city and county ordinances and state laws PERMrr ISSUANCE FEES PAID:
T relating to building construction,and herebyauthorlmnepresamativesofthb
H Z city to enter upon the abovo-mentioned property for inspection puryoaes. ALTERORADDTOMECH. Date R2Ce1 [#
_ (We)agree to save,Indemnify an d keep harmless the City of Cu pen Ino
against liabilities, aroNeand expenses which may In anyyQy gpcnte AIA HANDLING[WIT(IO 10,000 CPM) :TAX
AL:
ag.Wt said City in con ens ofthe gnntingofthlepe
AIRHANDENGUNTr(OVFRIQ000CFM) CONSTRUCTI
AppOa c n Dae EXHAUSTHOOD(w/DUCT) CONSTRUCTIAID:
HAZARDOUS MATERIALS DISCLOSURE
WIIl the appBesnt or(utdm building occupant store or handle ha>ardous HEATING UNIT(TO 100,000 BTU) Date t#
macrlalas defined by the Cupertino Municipal Code,Chapter9.IZ and theHealthandSafety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTI!! AL• LCY
❑Yes r]No -
Wllltheapplicantorfulurebuilding occupant use equipment ordevices VFN"ILLATION PAN(SINGLE RESID) WF/�JCE DATE
which emll ham minus aircont.onhunts as defined by the Bay Area Air �i IJ
Quality Management District? BOILER-COMP OHP OR 100,DW BTLa
l�Yes �No EC •`-�
ve mad the hazy ous materials mquiremenh under Chapter&95 of BOILER-COMP(OVER IW,000 BTU) Jnnn
the Cali(o it.Health&Safety Code,Sections 25505,25S33 and 25534. 1 7 .7x7/
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL ME CH. SQ.Irr /tl�r
responsibility to net lfy the occupant of the mTumet M1
lreenta which must be m �rW�tnll(iJ
prior to lssuCe
a not of a rtificate of Occu panty. u
Owner or authorizes agent Date ISSUED BY: ,�
TOTAL.:
OFFICE COPY