23896 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Prom Identification I'FRMITNO.
Building Address: f- 1. . 23896
dross ams: one:
APPU?7KrD7M797nTA—M A
CITY OF CUPERTINOBUILDING DIVISION
//'� r�
con a aJ.Na a APPLICATION I PERMIT h:Li2
t� BUILDINC-MFJCTRICAL.PLUMBINGMECHANICAL CATEGORY CONTROL N
Archaect/Eglneer. ric N.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PFJ MITISSUANCE / .® ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I lath Secion7OOMtlaiv Bcm.edunder Busin Wonso(essioner9 ie,and c APPLIANCES-RESIDENTIAL DESC s170N
in rrac I.ectl ll lo.and a felon3olthe Bualnessand ProfeasimnsCode,and my t�
Ilrend It In ful rce and effect. PANELS Q%� law
' Llrend 1 ss Lie N
Date Contractor —UP TO 2DO ANTS
CHITECPS DECLARATION 201-1000 AMPS
9 ZO lundentand my plans shaRbeused as pub0rero
crds. OVFRIODDAMPS SQ.FT.FLOOR AREA $/SQ.FT.
Ei Licensed Professional SIGNS ELECTRICAL
<<�-d� OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC
7hF�' Iherebyaf0rmthat lam exempt from the Conlractorb License law for the
folWwing reason.l5ectlon 7Qe15,Business and Professions Cade:Any city or
I- TEMP.ME17R OR POLE INST.
courtywhichF� anystrcoun requires pertNeto constract,alter,eaLsorquingstheapmvgdemoWh,ermitto
$$q any a signurcpdemoIts hauamealce sed pursuant to the fmmeomof t e )OWER DEVICES
�1 O 5
file a atgned statement that he t r9(cod pursuant it the proaltom of the
8 3 0 ContractoJs License law(Chapter 9(mmnenting wilts SeR1on 7000)of Divi- SWIMMING IDOL ELECTRIC
t., sion3of the Business and Profedlom Code)orthal he is exempt therefrom and VALUATIOL4
5g—<X the baeb for the alleged exemption. Any violation of Section 70315 by any ^ rear/
( applicantfor a permit subjects theapplicant to a civil penalty of not more than OU7LETSSWITCIiESFIXNRFS O I O
E fiF11,asrowner ars of
property,
ro NEW RESIDENTIAL ELECTR SQpT. SIOWES TYPECONSIRUCTION
GQQQ1 �n ❑Laaoon,.01 oche work,andrmy empbyenwllhwagu aetMred fa
C
compensation,Boldon.and Professions
Code:The
or License
Law
5 O dale(Sec appy to alnowandf prop ons Code:The builds or Improves
hereon,Law
$ doss nonsucht apply tomowner ofp rough whonemorimprwvided that
ryuch OCC.GROUP RFS.UNITS
hh.• whoand
does
are not msended or oraugh Neow ale.If owe,prwhebuil ingot
Improvementsarenot Intendedorafferedforeale.If,however, Uder ldingve
Improvement Iswld within oneyearolcomplellorylheawner-bullderwW have
thc_tjrdea ofpmving that hedid notbuildorlmproveforpurpowofule.). QTy. PLUMBING PERMIT FEE
LJ L as owner of the property,am exclusively contracting with Dimmed FLOOD ZONE APN
amtracron to construct the project(Sec.76/4,Business and Professions Code: PERMITISSUANCE
The Contractors License Law does no apply to an owner of property who '
Wilds or improves thereon, and�who contracts for such projects with a ALTER-DRAIN&VENT-WATER(W
mp((aIdor(s)Reeved pursuant to the Contractor',Contractor',Licame Law. FEE SUMMARY
am exempt under Sec N B&P C for this reason BACKFLOW PROTECT.DEVICE OUTSIDEF
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
_ Owner Date
WORKMAN COMPENSATION DECLARATION RECEIVE NPICTURES PER TRAP 5CI100L TAX Y N
❑I hereby a((Irm that I have o lnaui ute of consent to opytnereo ore RECEPT N
MM,L.teo(Workers ComperaaHoninsuranremarertifled copythereof Wee. GAS F.A. YSIEMI INCA OUTLETS;3BOO,Iab CJ -PARK FEE Y_ N_
Pollry N GAS EA.SYSTEM-OVER p(EA) OINGRECTDI p
Cam any BUILDING DIVISION FEES
❑pCertWed copy la herebyth the city
GREASE/NDUSIRL WASTE INTERCEPTOR PLANCHECK FEE it
Certified copylallled with the ciylnspectlon division. RO
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID 4 '�S
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 20Wr( Date Recei t#
Rhin eetimn need not be completed Lithe permit V(prom hundred dollars
(SI IcorlWATER HEATER W/VENT/MECTR ENERGY FEE Y N
Irerti(y that In the performanceo(the work forwhich this permit is Issued,
I shall not employ any person In any manner n as to become subject to the WATER SYSTEM/7RCATING
Wmixeri Compensation Laws of Calff.U. Data PAID
z Z Applicant NEW RESIDENTIAL PLMB. SQYr. Date Recei t#
Z O NOTICE TO APPLICANT:If,after making l hie Certificate of Exemption,you
fshould Rinne subject to the Workers'Compensation provisions of the Labor TOTAL
N Code,you must forthwith comply with such provisions orthle permit shall be
1 deemed revoked. BUILDING FEE
Sp CONSTRUCTION LENDING AGE SEISMIC FEE
I hereby aWrm that there lee comlmction leading agency for the perform- ELECTRIC FEE
7 O ante of the work for which this permit is Issued(Sec.3097,Civ.CJ TOTAL. ELECTRIC EEE
V I<ndefa Nasse
LL ~ I-enderb Addend QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1 duttlythatl havercadthiaappllcatlosand orate thattheabove Information
G tomoct.7 agree tocomply with all cityand county ordinancesand elate laws PERMITISSUANCE FEES PAID:
} N relaling to building construction,and hereby authorlac representative.of this
F Z city to enter upon the above-mentioned property Em inspection purposes. ALTER OR ADD TO MECH. Date Reeei t#
V — (We)agree to save,Indemnify an d keep harmless the City of Cu pert iso P
agaimtllabilltles,jodgments,cortsan ex pends which may In any way accrue AIR HANDLING UNIT(TO 10,000 CPM) SUBTOTAL:
againstaa In con esu grnt In this permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
S natu Again
ctor Data EXHAUST 1LOOD(W/DUCD CONSTRUCTION TAX PAID:
HA D US MATERIALS DISCLOSURE
Will the applicant future building occupant store or handle haaumlous HEATING UNIT(T0100,0MBTU)
moterlal as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date RCCei !
Health and Safety Code Section 2M32(a)I HEATING UNIT(OVER 100,M BHp TOTAA
VYes r]No
Ill theappliant or future building occupant sad equipment or devices VENTILATION PAN WINGLE RESID) ISSUANCE DATE
which emit haaardous air contaminants as cleaned by the Bay Area Air
Quality Management District? gO1LER-COMP OFNOR 100,0W BTU) pg p P9 F4,
4 Yin No V'
have read the haza ons materials requirements under Chapter 6.95 of BOILER-COMP(OVER100,000 BN)
the CaliforniastandtHealth he building
Code,Sod ions 25505,ently ve a tenant,that
iunde `JUIN 25 199
responsibility
that if notify
the occupant
does nut emquirang".w which
that It is my NEW RESIDENTIAL MECFi. SQ.FT.
roponslbllity to notify the ompant of the rcqulrements which must be met
prior to issuance of a Certificate of Onupancy,
rtnulr
(Tuner or authorised agent Date ISSUEDBY..
TOTAL:
OFFICE COPY