23082APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification I
Oudding Address: Oia,:.O 5 a. C' B
PERMIT NO.
23082
Phone:
A =A
,..�
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDINGELFCTRICALPLUMBINC-MECHANICAL
—b
C& /�. Lic.No:
(--
CATEGORY
CO
Architect/ gineer. Llc. No: '
OTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Addreae
PERMIT ISSUANCE
❑
LICENSED CONTRACTOR'S DECLARATION
—
Ihereby nnthat arn licensed under provisions Chapler9(commm
Ingwith5oction7000)o/Divelon3ofthe BudmsnandProfeulonaCadeand my
littneela In full and dfect.
Llcnnse Cla LIc.NS
MPEANCFSRESIDENTIAL
JOB DESCRIPTION
PANEIS
Dale Contactor
U
17
-1000 AMI"'
ARCHITECT' DECLARATION
errand my phns ahaB bo used u public records
OVER 1000 AMPS
SQ. FT. FLOOR AREA
S/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
SPECIALCIRCUIT/MISC
OWNER -BUILDER DECLARATION
I herebya(fldnthet I am exempt from the Contractor's License law for the
TEMP.METERORPOLEINST,
following reason. (Section 7011.5, Business and Professions Code: Any city or
countywhlch requ res a permit tocomtmd, altey impmve, demolbh,ormpair
'
anystructum pciorto Its hauance,aLwrequiresthe applicant for such permit to
Ok a signed statement that he Is licensed punuam to the provisions of the
Contractor's License Law (Chapter 9(mmmencing with Section 7000) of Divi-
slon3 ofthe Business and Professions Code) orthat he V exempt therefromand
the bash for the alleged exemption. Any violation of Section 7031.5 by my
appdcant fora permit subjedstheapplicant to a dvil penalty o(natmorethan
five hundred dollars (S509).
❑I, as owner of the property, or my employees with wages as their sole
compensation, wllldolhe work. and the structure is ent intended or offered for
POWER DEVICES
SWIMMING POOL ELECTRIC
}}��
1TILETSSWITCHGSEXTTJRFS [..J
/'1� VALUATION
r1 4% O
l 1�
i TYPECONSTRUCTION'
''
NEW RESIDENTIAL ELECTR FC.ax
SQ
sale (Sec 7060 Busbsss and Profesaluru Code: TM Contradare License Law
does not apply to ark owner or property who nWild, or Improves thereon,that and
ee,p,
whodoementsa
ntededoff rough hisowneered
� N
R
out . If,ho thebthalsuch
or
improvement issold ithindneyear fcompletion the ower-buthierwding l have
Improvementhsold within oneycarofcompldlon,lha owner-budderwill have
70T
O
`l
thLkurdenofpmvingth9]s,did nmbuddorlmpreve(orpurpossofsale.).
L as owner of the property, am exclusively contrading with licensed
mntradon to construct the project (Sce. 7044, Business and Professions Code:The
QTY. PLUMBING FEE
;PERMIT
PERMIT ISSUANCE
FLOLI
Contradorb License law does not apply to an owner of property whoALTER-DRAIN
or Improves thereon, and who contracts for such pkrjeda withm,RVador(s) licensed pursuant to the Conorador's Llmnse Law.
LI I am exempt under Sec. B k P C for this reason
Ar VENT- ENWilds
BAIX FLOW PROTECT. D
FEE SUMMARY
OUTSIDE FEES
DRAINS FLOOR ROOF, AREA, CONO.
FIXTURES PER TRAP
SANITARY Y_ N
RECEIPT# .
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that 1 have a mrtiBcate of consent to self -Insure,
SCHOOL TAX Y N
or a
ce0f,Labo(Worker Compensation Insurance oraartifled copythereo((Sec.
380f,Lab C.)
RECEIPT#
GAS EA. SYSTEM -1 INCA OUTLETS
PARK FEE Y N
Policy tl
RECEIPT M
Com an
S GAEA. SYSTEM-0VER4(EA)
BUILIIING DI VISION FEES
[Y
Certified copy Is herebytd.
❑Certified copy t tileddwwithh the the city inspection division.
GREASE/INDUMRL WASTE INTERCEPTOR
PLANC- KFEE
GREASE TRAP ,
CERTIFICATE OF EXEMPT ION FROM WORKERS'
COMPENSATION INSURANCE
(Thisacnlon need not W completed if the permit Is foronc hundred dollars
(StaO)orly thatthe nearworso as to beht pesublocmit is a. thecci,
I ttrun employ any perhe son
1 shall rx employ any penwn In any manner n u to become subject to the
I. any
Worker Compensation Lowe of Callfornla. Date
PAI
Regie #
SEWER -SANITARY -MRM EA. 200FT.
WATER HEATER W/VENT/ELECTR
EE� N
� � Q
PAID �
WATER SYSTEM/TRFATING
Applicant
NOTICE TO AP
NOTICE icate, after making this Certifo(Evemption, you
should become subject to the Worker Compeuatlon provisions of the Labor
Code, you must forthwith comply with such provisions orthis permit shall be
deemed revoked.
Date 1 f#
NEW RESIDENTIAL PLMR. SFT'
TOTA
6 ILD G
_
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I herebyafiirm that there is a construction lendingagenblry forthe performance of the work for which this permit t Issued (Sec. 3097, Civ. C.)
Lender's Name
Lenders Address
Iscenl/ythetl have read thisapplicatlon and statethatthe above information
Is correct. i agree to comply with all city and muntyordlnances and state laws
-
Q'R'. MECHANICAL PERMIT FE E
PLUMBING FEE
MECHANICAL FEE -
( PERMIT ISSUANCE
FEES PAID:
relating to building mutmction, and hereby authorize mprcxntativu of thio
city to enter upon the abovesmentloned property for inspection purposes.
e) agree to save, Indemnify an d keep harenle a City of Cupertino
,
Datc Recei t#
TERORADDTOMECH. �
SUBTOTAL:
shot a ts, expensesw h yinanywayaccoe
a aWtsald a.a anting IN �It.
/ '
AIR HANDLING UNIT (TO IO,ODOCFM)
AIR HANDLING llNTT(OVIR 10,000CIM)
CONSTRUCTION TAX
Signature of Applicant contractor Date
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
-
Will the applicant or future building occupant store or handle hazardous
material as defined by the Cu RRBIIBeeeeee111XXX'tttino Municipal Code, Chapter 9.IZ and the
Date RECTI t#
HEATING UNIT (OVER 100,000 RTU)
T A
IlealthandSafetyCod25532(a)7
❑ Yes IIJN.
VENTILATION FAN (SINGLE REED)
ISSUANCvE'DATE
�P0.P 1 LUJ
tlss.—
�s 25999
/s ,}
CITY Vi' LV i CTT l li y
Will the applicantor.futureW Ing occupant weequlprrent ordevims
which emit harardoue air cont nant as defined by the Bay Are a Alr
Quality Management tri
4 Yrs o
haveread the Maas outrtode,Setions 25505, underChapter2554.1 of
the California Health &Safety Code, Scdlou 25505, 25533 and 7.5536. I
understa nd that if the building does not mrmnt)y have a tenant, that It is my
responsibilityto notify the occupant of the reqm
uireent which most be met
prior to issuance of a Certificate of Occupancy.
BOILER -COMP DHPOR 100,0(0 BTU)
BOILER -COMP (OVER 100,000877p
NEW RESIDENTIAL MECH. SQ FT
ISSUED BY
Owner or authorized agent Data
OFFICE COPY