23941 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification I PERMITNO.
Building Address: �v�P � . 23941
era a : anO AFFU�lIUN Submit JAL DATE
CITY OF CUPERTINO-BUILDING DIVISION
Cortradme•eName: _ Lk.No: APPLICATION 1 PERMIT L
L/ /�L� Rg%c BOLDING-ELECTRICAT PLUMBING-MEEIAMCAL CATEGORY CONTROL N
Archil Le meso Lir.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Aaamaa 5027 /N✓GjSTt7 v W r c%G' PF]ihUTIS UANCE ❑ 1:1
❑LICENSED CONTRACTOR'S DEC RATION
I hereby dflmo that l am Remand under provisions of Chapter 9(commenc APPLIANCESRESIDENIAL JOB DFSCR[PHON
se
Ingwlth ful7000).f Division 3o(the BudwaandProfnalonet7ode,andm 1
lice. is InIn full to and dfect. p PANELS NbVla�/aW(��t1giV�.IaYyL��,����/y
Llcenm Cb Le.NR��
Dat Contactor
01
ARCHITECTS DEC T 201-1000 AMPS
COC 1 understand my plana$hall be used as public a OVER]000 AMPS SQ.Fr. AREA $/SQ.FT.
y�y U Licensed Professional SIGNSELECTRICAL _ Y '
6 OWNER-BUILDER DECLARATION SPECIAL CIRC[11T/M1SC 1 D '
I herebyafRrmtMt l son exempt from the Contractors License law for the /j �j'] I p I
OZ following rcanon.(5wian 7011.5,Business and Pmfealons Code:Any city or TEMP METER OR TOLE INET, 'fl �"' V
.."hid,m"brsa permAtoomermet,alter,impmve,demolish,orrepair
��EE anb v y$tmmmpdartoltebmance,alsorequimatheappllcantforsuchper tto POWER DEVICES DA 7 I 1
K file a dined statement that he licensed pursuant to the proviaoof the
Contractor.License Law(Chapter9(mmmendngwlth Section 7000).(Diel. gWA4.0NGIWLELECIRIC
don3ofthe Budnessand Pro—WCoae)orihathebexemp'thercfromand VALUb110N
the basis for the alleged exemption. Any violation of Section 70715 by any
applicant fora permit subject.theapplit.et to a civil penalty of net rrorc than OUILET55WITCHFSHXTURES 11/1/fa�
five hundred ddhn($500). CV.J4v�
I,as owner of the property, NEWRESEDEN71ALELECTR_SQ.FT. STORIES TYPE CONSTRUCTION
�n p perry,ci my employees with wage as thele wk
rompenadon,willdothework andthestcode: h mont.c e License offeredfor
O sale(Sec. pplyOOA to anewandf Property Codi The Contractors hemon Law
docs 3� whodetapply tarn owner orthrou hhisaw who empoyees,p vesthereoryand - OCC.GROUP RFS.UNITS
whodoementssauch w nothimself nded mothered
ugh Maewne.If,ho eprovidedthatsuor,
Improvementsarenot Intends ye.rferedforeale.If,however, iWer ilI have TOTAL:
improvementtawldwlthln oneyearofcompldlory Meowner-bullderwlll have '
thCburden of proving that he did nm build or improve fee purpose ovale.). Q7y, PLUMBING PERMIT FEE pEDppNE pPN
1:1 1,as owner of the property,am exclusively=trading with licensed pp IT LSSUpNCE
contractees to construct the project(See.70K Business and Profenforu Code:
Th.Contractor.Lt...Law does not apply to an owner of property who
WALTER-DRAIN k VENT. IFA)
builds or Improves therms,and who contra. for such plajeda with• FEE SUMMARY
MINdenial licensed pursuant to the Contradm's License Law.
IN am exempt under Sec B&P C for this reawn BACK FLOW PROTECT.DEVICE
'� Owner DRAIN&FLOOR,ROOF.AREA,COND. SANITARY Y N
Date RECEIPT Y
WORKMAN COMPENSATION DECLARATION FIXTURF-PER.IRAP SCHOOL FAX Y N
[]I hereby affim,orkem that I have a certificate of consent to ee0-lneu ora RECENT N
3800,Laeo(Worken'Compewtlonlnunnce mattrti(kvl ropythemof(Sec. GAS EA.SYSTEM.11NC4 OUTLETS _
Policy 11 CJ PARK FEE Y N
Pall Y
Co ry RECEIPT
ray If
GAS EA.SYSTEM-OVER 4(EA) BUILDING DVISION FEES
nrtlnedmpyi hercbyfumisheaLA
. CREASE/INDUSIRL WASTE INTERCEPTOR
PNCHECK FEE
Certlfled ropy b filed with the dry Impaction division,
CERTIFICATE OF EXEMPT ION FROM WORKERS' CREASETRAP PAID
COMPENSATION INSURANCE SEWRR- STORM-STORM EA.200FT. Date RO@I
Uhlsaes.) need nU be camplded i/the permitIs larane Fundned dollars P[#
($100).rfy that
WATER HEATER W/VENT/ELCCTR ENERGYFEE Y N
]certify employ
the pee race,b,
ny a work foe to become
Permit Is booed, —
I.hail nm employ any pen.n f any manner at a to become subject to the WATER SYSTEM/TREATING
Worken'Compensation laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. Date Rewi t#
Z O NOTICE TOAPPLICAM:ILafter making this CertlfkateofExemp[bn,YOU —�}T
ebmld bm....bjed io the Worken-Compewtion pmWbm of the Labor TOTAL:
N Code,you moat forthwith comply with such provision or this permit LLIlbe B �e
LU > deemed revoked. INC;ECE
LU
C CONSTRUCTION LENDING AGENCY SEISMIC FEE
Ihercbyaf(Irm'bat there is a controdion lendingagenry(or the perform- TOTAL: ELECTRIC FEE
0 ae.doe.ework for which this permit b inced Sec.3097,Cie.CJ
lander.Name PLUMBING FEE
LLU Linder.Aaarea
QTv. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icarlfythatl have readthisappfatlon and matethatthe above Information
IL Is correct.7 agree to comply with all city and county ordinances and mate laws PERMIT ISSUANCE FEES PAID:
} Nrelating to building contmdion,and hereby authorive representatives of this�. Z city to enter upon the above-rrentloned property for Inspection purpoas. ALTERORADD 70 MECH. Date Recei t#
— (We)agree to ave,Indemnify an d keep harm less the City of Cupertino
a Surat Ila ftlea Jodi n,cMsand expenseswhkhmsylRanywayamue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL'
againta CI .ettre of tI:e;Zing nithla permit.
AIRIIANDLTNGIINH'(OVER IO,OOBCFM) CONSTRUCTION TAX
gntu f cat Coot or Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
A RD S MATERIALS DISCLOSURE
Wlllthea fact low building occupant store or handle himmious HEA TING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health hand Safety Code Section 25532(a)? HEATING UNIT(OVER 100a No ,000 BTU) TOTA
Will the applicant or turcbulldingoccvpant use equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazaedous air contaminants as defined by the Bay Area Air
WtaBty Management District? BOILER-COMP p11POR 100,000 BTU)
Yes No
have read the bazar Pus materials requireetenb under Chapter 6.95 of HOMER-COMP(OVER 100,000 BT U) P� p
he Ca llfomla Health A Sefdy Code,Sect ton 25505,25533 and 25534.1 R� 4 I D
and data nd that if the building does not avrrently have a tent n,that it iii my NEW RESIDENTIAL MECH. SQ.FT
reeponlblllty,to notify the..pant of the requirements which must be met /N�
prior to Issuance of a Cedtflate of Occupancy. {/ 7
tTvnerorwthmlucit
degent Date ISSUEDBY:
TOTAL: r
OFFICE COPY