23718 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE SALL POINT PEN ONLY
Building Project identification PERMIT NO.
Build Ing AddO S�� g • 23718
nets allr/re: on p
YL!l� G110125S-7 CITY OF CUPERTINO-BUILDING DIVISION
nt
coradmaName: Lie.No: APPLICATION / PERMIT
J'u' &'• BUILDING-0MECTRICAL�PLUMBINGMECHANICAL CATEGORY CONTROL X
Architect/Engineer. Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ ❑ I�1, E:1LICENSED CONTRACTOR'S DECLARATION -
Iherebyatflrm'hat lamlicensed ftheunder ofChalyter c APPLIANCES-RESIDENTIAL , JOB DESCRU'HON
11...M1 In
force anDlNect. ftheguslnemandPro(essloneCode,and my
Iiconx b in full force and effete. PANELSFwsvo
LiceDate Class LieX 11�y
Date Contractor cow \
ARCHITECTS DECLARATION 2014OOVERDIIAMPS �A e�w
�2 I understand my plan s1uB he used as public recon1X 1000 AMPS
SQ.Ff.FLOOR AREA 5/SQ.FT.
O
x Licensed Professional SIGNSELECTRICAL
OWNER-BUILDER DECLARATION SPECIAL CrRCU1T/MLSC
IhercbyafOrm that l am exempt from the Contractor's License Law for the II 1'm,% tl
Zp following reason.(Section 70'11.5,Business and Professions Code:Any city or � , n r� _
TEMP.METEROR POLE INST. IIII P, 7
K coantycture pruntoss Wontneocovtmuireatheaprove,demoRth,or repair �• 1
anyalvcWrc pdorto its lssuance,alsa requlrestheappllcant for each permit to POWER DEVICES
file a signed statement that he Is licensed pursuant to the provlslov of the
3w Corrado.License Law(Chapter 9(commencing with Section 7000)of Divi- t, 17;7_E UATION I(
EOg sion 3 of the Su einem and Professions Code)or that he is exempt therefrom and SWIMMING POOL ELECTRIC 1
< the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS-SWITCHES-FIXTURES
fora permit subjects the applicant to a civil penalty of not more than
o.o, flue hundred dollars(5500). NEW RESIDENTIAL ELDCTR SQ.ET. STOWRS TYPE CONSfRUC7'ION'
�f �n ❑I,as owner of the property,or my employees with wages as their sole
compensadoq willduthe work,andthe structum toner Intended or offered for
❑
.is(Sec.70K BusinessandProfessions Code:The Cormactoea Llmrue Law
�$ does out apply to an owner of property who builds or improves therron.and OCC.GROIIP RFS.UNITSwho don such work himself or through lesown employees,provided that such
Improvement arena intended proffered torsade.If however,thebuili ing or TOTAL:
Improvement t sold within omyearofcompleion,the ownenbullderwiil love
1ljLku rden of proving that he did not build or improve for purpose ofmleJ. QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
U L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractor's Llrense Law don net apply to m owner of property he ALM-DRAIN&VENTWATER(EA)
Wilds or Improves thereon,and who centrads for such p(ojeets with a - ',FEE SUMMARY
ugp(r!dor(s)licensed pursuant to the Contractor's License Law, gpCR FLOW PROTECT DEVICE
L-f I am exempt under Seo B k P C for this reason
Owner Date
DRAINS FLOOR ROOF,AREA,GOND. S TARY Y
REC p_
WORKMAN COMPENSATION D[CLARATION p1 TURES PER TRAP e00L TAX Y N_
❑wftifl teof affirm that I have o Imum to of consent to self-instueopytherso ora RECOPT X
3800,Lab Worken'Compensatlanlvuranco ora cortl(kd ropythereo((Sec. GAS EA.9YSTEM-1 INCA OUTLETS RK FEE Y N
3Xlic lab CJ
Policy M RECEIPT M
CAS EA.SYSTEM-OVER 4(EA)
Cam any BUILDING DI VISION FEES
CertNed copy t hereby tci d. GREASE/WDUSIU,WASTE INTERCEPTOR PLANCF CIK.E•t•�
�Certified ropy t filed with
the the city Inspect[on division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE -SA ABY-SNRM EA zooF 1. Date Recei t#
ffht section need not be completed If the permit t farone hundred dollars
(E100)oy(h WATER HEATER W/VENT/ELECTR ENERGY FEE Y'— N
Icertifl(y that In the performco
ana(the work for which this permit m
tisted, —
I shall not employ any person In any manner so as to became subject to the WATER R SYSTEM/TREATING
Wm1wra Compensatkm Lawsof California. Date PAID
0 Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date ReMI [#
Z Ch Nould Wasme PLICAtot a orkersk o this Certificate o(Exe of the ,lbo
should become subject it the Workers'Compensation provtione of the Labor TOTAL:
~ N deemed
must.forthwith campy with each provisions ortht permit shall be
W > deemed revoked. B12IL12ING FEE
CL c CONSTRUCTION LENDING AGENCY SEISMIC PEE
I hereby affirm that there is a construction lending agency forthe perform ELECTRIC FEE
M Z arev of the workfor which this permit t issued(See.3097,Civ.C.) T
U Q lender's Name PLUMBING FEE
LL X- ]enders Addreas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW 1cortifytha l have read thisappRotionand atatethat theabove lnformatlon
1 tmved.I agreeto complywith all cityand county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} y relating to building construction,and hereby authomm erpresentativesofthis
Z city to enter upon the above-mentioned property for impeca purposes, ALTERORADDTOMECH. Da[C RL'cel t#
(We)olives to save,Indemnify an d keep harmless the City of Cupertino
ago Inst liabilities,Ndgment,costa and expenses wh lch may In any way ansae AIR HANDLI NG UNIT(TO 10,000 CFM) SUBTOTAL:
xgalnotsald Ci Inconseluen the grand p=t.
AIR HANDLING UNIT(OVER ID,000 CFM) CONSTRUCTION TAX
6 _sl atvreof Apphmn on dor Date EZHAusTHOOD(W/DUCD - CONSTRUCTION.TAX PAID:
H , I DOUS MATERIALS DISCLOSURE .
Will the applicant.1 hiture building occupant store or handle hamniom HEATING UNIT(TO 100,000 BTU)
Date - RCCCi t#
tcrial ss defined by the Cupertino Municipal Code,Chapter 9.17,and the
Hnllhand Safety Code Sectlon25532(s)7 HEATING UNIT(OVER 100,000 BTU) TOTAL 6�
❑ Yee L No
Will the applicant orfutum building occupant use equipment or devices VENTILATIONEAN(SINGLERESID) ISSUANCE DATE
which emit haeardous air contaminants as dented by the Bay Area Air
Qua lily Management District? BOfLER-COMP OFU'OR 100,!00 BTU)
'T Yn N No
have mad Health
So out materials
ection mmcntundeand 255 .I of BOILER-COMP(OVER 100,000 RTU) PAID the California Health WildinSafetyg
Cods,redbnsntly h b533and,that ] K B
understandthatyto If rthe lly the occupant note currently whicave a hLthat it troy NEW RP9DENTIALMECH. SQ.FT. rs_
rmpovlblllly to raptly the occupant of the requirements which must be met NAY,02
199 prior to issuance ofaCedlticate of Occvpanry. n %w/
Owner or authorized agent Date TOTAL: ISSUED BY: _
•
OFFICE COPY