23243 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Addms:
.,:)/?to 23243
nils one:
•¢ Re tlavjpoJ CITY OF CUPERTIN6BUILDINGDIVISION '
Amchitea/Englmer. _77> 1- q2
Co
•"•^• () APPLICATION /PERMIT
�• BUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL X
' Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addrev PERMITISSUANCE 1:1 ❑ 1:1LICENSED CONTRACTOR'S DECLARATION
Ihereby
on7OBest lemlke3.fthunder prwlslonaofChapter 9fmion.0(mmmrnc APPLIANCES-RESIDENTIAL JOB DFSC$`�{ION-
Ingwlth SeMon force and effect
ProfcasiomCode,and my a U`'`
license Is Ins force anddied. PANELS
Ec.If
DateClass Lontr
Date Conlrector ' UP TO 200 AMPS
ARCHITECTS DECLARATION 701-1000 AMPS
µppµ!as ftp I understand my plain shall be used as public records. OVER1000AMPS SQ.FT.FLOOR AREA f/SQ.FT.
E e, Licensed ProfemWwl SIGNSELECTRICAL
G< OWNER-BUILDER DECLARATION SPECIAL CBtCIRT/MLSC
7 p., Ihereby.?@m that l am exempt fecmthe Contractor's License law forthe
following reason.Section 7031.5,Butlnem and Profealons Code:Any city or
I..,�ORTCMP.METER OR POLE INST.
� countywhlchrequimsapermlttoamtmdalter,lmpmve,dem^ll•h,orrepalr
q nystmmmpdortoibimane,a)wrryubeslheappBmntforsuchpemdtto POWER DEVICES
G file a signed statement that he is licensed pursuant to the provisions of the
Contredor'•License Law(Chapter 9(mmmencing with Section 7000)of Divi. SWIMMING POOL ELECAEVALUA
�Og sl°n3of1he8ueinneend Pro(embmCode)°albs he tm
eturpttherefroand
�^ the basis for the alleged exemption. Any violation of Section 70715 by any sit,
-I
eppilcant Sore permit subject the applicant to a dWi penalty of na rmrethan OUTLETSSWITCHES-FIXFUR VV
fndrcd dollero($500). NEW RESIDENTIAL ELECTR STORIES TYPE CONSTRUCTION
�n I,as owner of the property,or my employees with wages as their sok
mmpervallon,wBldothe work,and thesmuclure is not Intended or offered for
q sale(Sees.7044,Deals .and Profeeslons Code:The Contractors License law
B does not apply to an owner of property who builds or irepr°vm thereon,and OCC GROIRa FEES.UNITS
who doescuch work himself orthrough his own employees,provided that such
Improvement arc not Intended or offered for xle.If,however,the building or TAId
Improvement t sold within omyearofcomplalon,the owner-budderwlll have
tle�urden of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT N FEE F=DTDNE APN
U I,as owner of the property,am exclusively contracting with licensed
contnoro mmproject pct(ctto mtct the j Seel044, er Bustand Professions Code: PERMIT ISSUANCE
_
The Coor Improves
License r, aces not apply to an owner a property who ALTER-DRAIN k VENT-WATER(EA)
builds tm Improves tFunnie and who mntade !a such plv)ects with a FEE SUMMARY
homsexi ant to the Contndor'aLlanx Law. BACK FLOW PROTECT.DEVICE
IL�JI I am exempt under Sec B k P C for this reason
OUTSIDE FEES
Owner DRAINS FLOOR ROOF,AREA,CONED. SANITARY Y N_
-• Date RFDEB'I Y
WOR KMAN COMPENSATION DECLARATION FIXTUI?FS PER TRAP SCHOOL TAX Y_ N_
❑I hereby ffl.mIumi that I have• lesurm a of consent to oey Chemo,ora RECEIPT N
certificate ofWorkers'Compensatl°nlnsuranamacertified copy thereof(Sec.
MOD,lab CJ GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
RECE
Parry Y DING DIVISION
N
CAS EA.SYSTEM-0VER I(EA)
Com any BUILDING DI VISION FEES
Certified copy is hereby filed
GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified mpyisfikd with the city inspection dlWslon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANHARY-STORM EA.700FT. Date Recei t#
ITh? need nee hecomplded If the permit?forum hundred dollen
(f100)orlenless3 WATER HEATER W/VENT/ELFI:'1'R ENERGY FEE Y N
Icertl(ythat In the performance of thework(orwhich this permit tluued,
I shall not employ any Person in any mannerist as to become subject to the WATER SYSITM/TREATING
Workcri Compensation Laws of California,Date PAID
ZZ Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Remi tN
O NOTICETOAPPLICANT:IL after mWng this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
V3 C°de,youmu•tf.ehwithmmplywith•uchpmvtiomarthtpermlt•hallbe BUILDING FEE
LU > deemed revoked.
IL G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hrmbyafflmn that there is e mmtrudlon lending agency for the perform ELECTRIC FEE
D O an.of the work for which this permit is issued Sec.3097,Civ.C.) TOTAL:
Lenders Name PLUMBING FEE
U. 1= Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1 cartifythat I haveread thtapplicatbnand getethr theaboveln(°rmatlon
1 tcorred.I agree tocomplywith all city and county ordinances and rate laws PERMIT ISSUANCE FEES PAID:
>. W relating to building construction,and hereby authorke representatives of this
Z city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH. Date R2Ce1 H1
_ (We)agree to save,Indemnify an d keep harmless the Cityof Cupertino
agar'agal t� mnts,mreand expenses which my lnanywayarerue AIR HANDLING UNIT GO 10,000 CFM) SUBTOTAL:
ag u n quenc fish granting of this pe R. AIR HANDLING UNIT(OVER 10,(DOCFM) CONSTRUCTION TAX
tureof Applica ontre 7113 2-
Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
H RDOUS MATERIALS DIS LOSURE
Wllltheapplla rfuturebullding.pant storeorhandlehavrdoua HEATING UNlT(TOIO(L000BTU) Date Recei tp
metertl as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety Cade Section 75537(.)? HEATING UNIT(OVER 100,000 BTU) TOTA
❑ Yes [ No
Will the appliantor ture Wilding occupant use equipment or devices VENDLATION FAN(SINGLE BESIDE ISSUANCEDATE ,
which emit hamrdous air cuntmimnts an defined by the Bay Area Air ff�?�aa pp
A
Quality Management District? BOILER-COMP DEEP OR 100,0470 BTU) iP O D
qYetI—I No
have read the hazar oua materials requlremnt under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the Calif°rnk Health A Safety Code,Sect[am 75505,25533 and 75534.1 dA111 fl� �aaa
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT YT�A1 3 9925
responsibility to notify the occupant of the requirements which must be met U�dY (•
prior to Issuance of a Certificate of Occupancy. CITY
QI•LUNCH l J
Owner or authorised agent Date ISSIIT:U6y � - V
TOTAL:
OFFICE COPY