23347 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Add re S6. s - 23347
ane:
nera� ane
IL . CITY OF CUPERTINO-BUIWING DIVISION
"trade,2 a ua.Na: APPLICATION I PERMIT 4
Ar hl EnBLnDINGELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL N
No:
Llc
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrc.s �d t� PERMRTISSUANCE ❑ El ❑
LICENS.D ONTRACTOR'SD CLARATIO
I hereby affm,that l am licensed under providera of Chapter 9(mmmenc- APPLIANCESRESIDENTIAL JOB DFSCKUIHON
(ngwehSection force anDlvfect. fthe Budneseand ProfenlonsCode,and my
' license hers fun forceanMvisio PANGS
License Chs Lle Y
Date Contracmr Ip TO
ARCHITECTS DECLARATION 201-1000 AMPS
a %2 I understand my plans shall W used as public records. OVER 1000 SQ,FT.FLOOR AREA $/SQ.FT.
CO SIGNS ELECTRICAL
is Licensed Professional '
�6tlB� LV
OWNER-BUILDER DECLARATION SI'[CIALCBtCU1T/M
2s' Iherebyaffirenthatlame.empt fromthe Contractor's License Law forthe
pp❑ following reactor.(Seetlan 7W 1.5,Business sad Profession,Code:Any cityor
FE~ cauntywhichmquimsapemdttommtmct,altenimpmve,den lIsh,ormpair P.METER OR POL INST.
'� any structure prior to its Issuance,also requires the applicant for such permit to
rNL file a signed statement that he Is licensed pursuant to the provIslom of the POWER DEVICES _
3 u,� Ccm.dor.Llce.IAw(Chapter9(mmmendngwith Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
1th05 don3oflhc Bu�nenand Prole®broCode)orthat he Isaxempt therefromand
{{{{��BS the ha,Is for the alleged exemption. Any violation of Section 70115 by any Q OUTLETSSW7TCHESFIXTURES D J1�r
appEcant for a permit subjects the applicant to a civil penalty of cast more than than C./fJ
$ live hundred demodollarthe property,
NEW RESIDENTIAL ELDCTR SQ.Fr. STORIES TYPE CONSTRUCTION
�s ❑I,asownerof theproperty,orhe employeeswithwages act offered
compensation,will H.,Botheworkandthestmnumis heC intended oroffendfor
90 nee(Sec appy Busmen and f property
rope ty Code:The Contractors Llmtua law
does not a pplyP',1$$ whodoesuch torn owner ofthroug hiswho
nemporimprwvidedes t osand hat such— OCCGROUP RFS.UNITS
WW wprove. eats amrkhlmselfedorwghhieowne.If,ho es,er,thedilding or
Improvements are not Intended oroffered for,ale.If, caner-p thebui ilI have TOTAL:
Improvement of proing tht oneyehe did or Wild
Improve fner-buose of sale.). QTY.tF1EJ,vrdenwner of the property,am
build orlmprovefactingor purposeoflicensed
QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
Lt 1,as owner of the property, S exclusively 44Buss ess and Pro with Is Code: PERMIT ISSUANCE
rontneron to construct the project(Sec appy Busmen and Professions Code:
The Contractor's License law darn not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon,and who contracts for such ptojem with a ,FEE$LIMMARY
mJJ Ltt((actor(s)licensed pursuant to the Contractor's Llc0law. SACK FLOW PROTECT.DEVICE
LI I lin exempt under See. B &"P C for this reason -
DRAINS.FLOO R SANITARY Y_ N_
Owner Date R OOT,AREA,COND. RECEIPT N _
WORKMAN COMPENSATION DECLARATION
01 hereby affirm ve that I haa artiBcate of consent to self-InFTXTIIRFS PER TRAP SCHOOLTAX Y_ N_
sure,or RECEIPT M
mrtificateofWorkers'Compemationhuuranmoracertifiedmpythereof(Sec. GAS EA.SYSTEM-1 INC.40UTLETS
3B00,lati C) PARK PER Y N—
Policy Y GAS PA.SYSITM-OVER d(EA) RECEBT x
CoCany B UILDING DI VI SION FEES
gCertlfled copy 6 hereby furnished. CREASE/MDUSTRL WASTE INTERCEPTOR
r7 Certified copy Is flied with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER—SANITARY—STORM FA 200Ff DBIe RCCeI t#
(This section need not he completed If the permit Is for...hundred dollars
(51I rd WATER HEATER W/VENT/EMFC'IR ENERGY FEE Y N
Ill our that in the performanceny of crohe oner
so as to which
permit to booed, —
I shall s' employ any perms In any manner su u to became mbject to the WATERSYSTEM/TREATING
Workere'Compenntlon Laws of California.Date PAID
Z Applicant NEW RESIDENTIAL PLMB. SQ.Ff. Date Remi t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Worken'Compemation provlslmu of the Labor TOT
N Cade,you most forthwith comply with such provisions or this permit Shall be BU G _
deemed revoked.
W
G CONSTRUCTION LENDING AGENCY SEISMIC FEE �—s
I hereby affirm that there is a construction lending agency for the perform- ELECTRIC FEE
Z an.of the work for which this permit Is Issued(Sec 3097,Civ.C.) 'TOTAL:
O O Lorder.N.me PLUMBING FEE
LL F Lender.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OWIcerifythatlhaVere.dthIsapplicatfonand..wthmt hcabaveinformatlan
CLI bronect.I agree to comply with all cityand countyardlnances and state laws PERMIT ISSUANCE FEE PPAID-
} N relating to building rovtmctian,and hereby authorize representatives ofthis
[— U) city to enter upon the above.mcntloned property for Inspection s, ALTrRORADDTOMECH. DBIC RCCei t#
V — (We)agrm to save,Indemnl an d keep harmlessthe uPool.. P
against abflt jodgenent,, sand rape which o ayaceme AIR HANDLING UNIT H010,000 CFM) SUBTOTAL:
ago Wt 1 mronsequ fthng of this I.
AIR HA NDLING UNIT(OVER I DODO CEM) CONSTRUCTION TAX
Ig W..fA a are EYHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
AZA OUS TERIALS DI OSURE
Will the applhant or future build occupant re or handle hazardous HEATING UNIT(TO 100,000 BTU)
mDate RCCei 1#
aterhlasdeflmdbythe Cupertino Mu cipal e,Chaptcr9.lZandthe
Health and Safety Cade Section 25532(a)? HEATING UNIT(OVER 100,000 BT() TOT
M Yes �]No
Wlllthcapplicaor or future building occupant useequlpment or device, VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which enetlhrardom air contaminants as defined by the Bay Area Air pp�� B
�usilty Mawgement District? BOILER-COMP OEW OR 100,000 BTU) PAID
L�Yea M No
f Ihavereadthe Ia -Mus materials reiulmorvnls under Chapter G95 of BOILER-COMP(OVER 100,000 BN)
tee CalRornIs Health&Safety Code,Section.25505,25533 and 25534.I MAR - 4 199
understand that If the notify
the ing doesoccupant note rreuiremoeatewhL that b is my NEW RFSIDENIIAL MECH. SQ.FT. 2�
responsibility mnotifythe occupant oftherently have
a a whichmust berrvrc
prior to Issuance m a Certificated O.P.acy. Cn� L)F GuptriillYV
Owner or authorlud agent Date ISSUED B
TOTAL: —
OFFICE COPY