23475 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Add 0 ;s ✓� 2347
e rc: Q one: p
(47j�— 0 CITY OF CUPERTINO-BUILDING DIVISION r�
Con ator's Name: Lic.No: APPLICATION / PERMIT LA �+
/014JI/nru 390359 BUG
ILDINELECTRICALPLUMBING.MEC}IAMCAL CATEGORY CONTROL
AnM1 /Engineer Lie No:
c ) BUILDING PERMIT INFO
QTY ELECTRIC PERMIT FEE
Address 3 r ST S11 PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby sabre that l am licensed under provisions of Chapter9(commene- APPLIANCES-RESIDENTIAL ]OB DESCRIPTION
It...h1.fan7000)o(Dlaffect o(theBuslnsssandlarategloneCade,and my
License le In full affect PANELS
PANELS ��
LlcenseC as Lk.,
s
Dale Con[nciora.—UP TO 2DOAHM
ARCHITE DECLARATION 201-10DO AMPS
Q CO I understand my plans shall be used as public records OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
I�U Licensed Pmfemiarul SIGNSELECTRICAL
OWNER-BUILDER DECLARATION SFFCIAL CIlCUIT/MLSC ED IN
Zp, Ihercbya(firmthat I smesempt from the Contractor's License Law for the T E R
cau
following reason. 7031.5,Business and Professore Code:An ct or
O F-� y ty TENIRMETERORPOLRINST.
I p ntywM1kM1 requirnapermitrororotmct,alteq improve,demolbh,orrcpair
anystrumre priortoitsluuance,Worequiresthe applicant for such permit to POWER DEVICESzi
�^'f
Oe a.� file s signed statement that he b ficensed pursuant to the provisions of the G/
3{0O Contractor's License Law(Chapter 9(mrmrencing with Section 7000)of DWI. SWIMMING POOL ELECTRIC
dneand
at.. BusoPmfesslmu Code)arthat he b exempt therefrom and VALUAIIbN
{E5< the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLE3SSWITCHESFIXNRES a///�s//3s ,�qqpp��
pO applicant ora permit subjects the applicant to a civil penalty of net morethan T/(/f N/V
cc five hundred dollars(y50OL C12
I,as owner of the property, NEW RESIDENTIAL ELECTRSQ}T. STORIES TYPECONSTRIICTION
�n p party,orheempoyegwithwagesrthelesole
compensation,wllldothe work,Prafesthetlmcturch.Is Cogradune or offeredLaw
O sale(Sec.?Daly to a now and Profegons Cade:The Contractor's License Law
$ docs not
ssuchtork ownerofproperty hisonemds orlmproes ovidedrcoRand OCC.GROUP RFS UNITS
who don eats amen himself ed orough hlsow lie.If yeas,provided that such
Improvementsarcnot ht one varo(co (orsale.If,h ner-p Uderwdingve TOTAL;
Improvement iseald wlthnone)earofcomplelion,theawner-W RderwRl have
ItILIxorden of proving that he did net build or improve for purpose ofsaoJ. QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
L as or of the property,am exclusively contracting with Ilangd PERMIT ISSUANCE
mat.&..to construct the project(Sec.70K Busoeg asd Freesia.Code:
The Contmctoes License Law does oat apply to an owner of property who ALTER-DRAW k VENT WATER(RPV
Wilda or Improves thereon,and who contracts tar such pnojem with a
egn4adca(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
Lf I am exempt under Sec. 0 k P C for this means
•
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N OUTSI -
Owner Date RECEIPT p
WORKMAN COMPENSATION DECLARATION
Ell hereby ere certificate that I have of consetont selbwFIX•NRFSPER.fRAP SCHOOL TAX Y N
in
re,or RECENT N
certiricab of Worken'Compensationlnsurenceara certified copythersa((Sec. GAS EA.SYSTEM-1 INC.a0UTLETS PARK FEE Y N
38licy CJ .� ��¢ / RE'CEIT#
C-m d>,�_: /G — 7 GAS EA.SYSTEM-OVER 4(EA)Con' nv_ /:.rani ^— - N� BUILDING DIVISION—FEES
rCenlfiend copy is hercbyth the dd. GREASE/WDUSML WASTE INTERCEPTOR PLANCHECK FEE
�GErtI(led copy is filed with the city Inspection division.
CERTIFICATE OF M(EMPTiON FROM WORKERS' GREASETRAP PAID
Get becu SAT10NIeparmt CE SEWER-SANITARY-STORM PA.200ET. Date Reset t#
(fhb sector need net W completed If lM1e permit is(or orm hundred dollars
(4100)orleg.)1 cartily that In the performance ofthe work forwhich this penalt is iftioned, WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
1 shall not employ any person in any manner so as to bemrre subject to the WATER SYSTEM/TREATING
Workers Compensation Laws of California. Date PAID
-
Z Z Applici^` Date Remi t#
Z O NOTICE TO APPLICANT.If,after making l his Certificate of Exemption,you NhW RESIDFNIAL PLMB. v(f.FI'.
Hshould become subject to the Workers'Compensation provisions of the Labor TOTAL:
W Code,you most forthwith comply with such provisions m thla permit shall be N
deemed mvokad. '
LU
0 CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirmthat there Is a constrodion lending agency for the perform- ELECTRIC FEE
7 Z ance ofthe work(or which this permit is issued(Sec.3097,Civ.C.) TOTAL:
U0 Lander'sName PLUMBING FEE
IL H Lendae.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W l certilythat l havereadthls applicalionand ante thattheabove Information
1 ismrmd.I agreeto comply withal)city and county ordinances and gale laws PERMITISSUANCE FEES PAID:
relating to building mnstmetion,and hereby authorize representatives ofthis
H Z city to enter upon the above-memoned property for inspection purposes. ALTER OR ADDTO MECH.
Date Revel t#
(We)agree to save,indemnify an d keep harming the City of Cupertino
agalnss liabilities,iadgmenn,men and expenses which may in anywayamme AIR HANDLING UNIT 0010,000 CFM) SUBTOTAL:
againsteal city ce he gr tingoftMsparmit.
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
tureof Applicant ontrador Dim FRHAUSTHOCK)MMUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wllltheapplicant or future building occupant store or handle havardous HEATING UMT('R7100,ODOBTU)
rnatedalasdefined by the Cupertino Municipal Code,Chapter VIZ and the Date Receiotf
Health and Safety Code`SMfoon 25S32(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL.
❑M
Willtheappllcant or future building occupant use equipment ordevims VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haearelous air cont.od.m.as defined by the Bay Arca Air
.
Quality Management District? BOILER-COMP OHP OR 100,000 BTU)
4 Ye, g— o
M1averead Healthe h
ar trCode,Sections
255nb5533 and 2SSr6.95 of BOILER-COMP(OVFR I00,000 BTU)
theerstadt Healthdr SafetyCode Sectlone25505,vea tenant,that
I APR
understand that if thenotify
the ing occupant note requiyments which
that b last NEW APSfDENTIAL MECH. SQFf '•a _ 199
responsibility to nMlfy the occupant of the requirements which rraal be met
prior to issuance of a Certificate of Occupancy.
CII
a Ne r
Owner or aulhodud agent Data ISSUED BY:
'IOTA L:
OFFICE COPY