23852 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project ldentlfleatlon PERMIT NO.
Building Add mss:
23852
ares: - one:
CITY OF CUPERTINOBUILDING DIVISION
ContmRor's Name: .GX APPLICATION / PERMIT
-A.10 BUILDING-ELECTRICALPLUMBINCMECHANICAL CATEGORY CONTROL#
ArcMlect/Engineer, Lie.No:
QTY ELECTRIC PERMIT F'F,g BUILDING PERMIT INFO
Addrcsc PFRhRTISSUANCE ] 1:1 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION l�J
1 hereby affirmthat lamdunder pinsCoIf C9(cone AIILIAN
CESRESIDENML �{tp0�/�ir O✓C fig'/
O-fiN
inSoctlonfsim3ofthe Busnessad Pro(CssI.O.bde,endmy JOB DE39W
licenseis in forceand effect. PANELS
License-Ws_
Dat CmtraL� Ar
ARCHITECTS DECLARATION
\n
00 AMPS
M ]understand my plans shall be used as public co
c rerds OVEROVER 1000 AMPS SQ.FT.FLOOR AREA 5/SQ.Fi.
O
Licensed Professional SIGNSELECTRICAL t 1 ewe'
�6g OWNER-BUILDER DECLARATION SPECULCIRCUT/MIST �' ro� LL� C D I • -
?R. owing reason.
election
7031reptlrothe.sand ntfessios icenseCodeo Law lm the
following reason.(Section 70315,Business and Prolembns Code:Any city or
O y. TQdP.METER OR]'OLE]NST.
P county which rcqulmapenNt tocorafmct,alter,improve,demollsh,or repair /
Y anyalructure priorto its Ouuance,also rryu4estheappllant forsuch pef/rmlt to POWER DEVICES
ail 5 file a signed statement that he la licensed pursuant to IM provislON of the �..�
ATE
Contractor's License Law(Chapter 9(commencing with Section 7000)o(Dlvl- SWIMMING POOL ELECTRIC
,J7 sion3ofthe Buslneseaud ProfemionsCode)mthat helsexempttherefromand VA TIO I'
the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS-SWITCHESFIXTU2RES
0� applicant for a permit subjects the applicant to a civil penalty of no repro than ,(s
$ five hundred dollars($500), NEW RESIDENTIAL ELECTR
❑I,as owner of the property,or my employees with wages as their sole SQ'FT' STORIES TYPE CONSTRUCTION
e � compensation,will do the work and the structure Is not Intended or offered for
5' O role(Sec 7064 Business and Prolemioru Code:The Contractor's License Law _
does not apply to an owner of property who builds or Improves thereon,and OCC.CROUP RLS,UNITS
who does such work hlmselforlhrough his own employees,provided that such
improvement.ere not intended proffered for sale.If,however,the building or TOTAL:
improvement beoid wlthln oneyearofcamptetlon,theowner-bullderwill love
the urden of proving that M did not build or Improve for purpose olsaleJ. QTY, PLUMBING PERMIT FEE FLOOD TONE APN
M 4 as owner of the property,em exclusively mntracting with licensed pphMlT ISSUANCEcontrnctms to..truct the pmject(Sec.7064,Business and Professions Code:
The Contoctor'.License Law does net apply to an owner of property who ALTER-DRAIN k VENT•WATER(EA)
builds or Improves thereon,and who contracts for such plokcts with• FEE SUMMARY
yt.(actor(.)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
IJ[am exempt under Sec B k P C for this reason
OUTSIDE FEES
DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECTI N
WOR KMAN COMPENSATION DECLARATION FIXTIJRF.S
PER TRA]' SCIdOOL TAX Y N
QI hereby affirm that 7 have•aminate of consent selbinsure,ora RECEIPT N
3800,Lab C.
certiflLsb C.)Worken'Comperuallon lraurance Oracerti(Ied copy thereof(Sec. GAS EA,SYSTEM-1 INCA OUTLETS PARK FEE Y N
policy#_//1/s^/ O 7� 2 GAS EA.SYSTEM-OVER _ RECEIPT#
om any BUILDING D IVIS ION FE ES
C5
a zyTnN copy ls herebyfumishm CREASE/INDUSIML WASTE INTERCEPTOR PLANCHECK FEE
Certified copy U filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
Cot beco
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Rail tit
(0)m Iccilon need not be completed](the permit V(Drone hundred dollen
(5100)orlyth) WATER HEATER W/VENT•/EIECTR ENERGYFEE Y N
Icertlfythat In the performance o(the work for which this penult is blued, -
I shag not employ any person In any manner so as;to become subject to the WATER SYSTEM/TREATING
WorkerYCompensstionhwsof C+Idorna. Date PAID
Applicant
Z Z N'OICETOAPPLICANT:If,after making thh CerBflabnf Exemptlon,you NEW RESIDENTIAL PLMB._5Q.Fr. Date RCtt'1 til
should becorm subjcct to the Workers'Compensstion provisions of the Labor TOTAL:
W Code,you must forthwith comply with such provisions orthh permit shall be U
W j deemed revoked. -
CONSTRUCTION LENDING AGENCY SEISMIC FEE
D O (hereby afnrmthattherebs r tmctlonb(Sic. Ctforth.pemorrry
ELECTRIC FEE
0O Leder'.Nwork!orwhichabperMtb4sued(See.3097,Civ.C.) TOTAL:
V Ixnder'e Name PLUMBING FEE
IL F Lcod.e.Address QTY.I MECHANICAL PERMIT FEE MECHANICAL FEE
OW I cemifylhot l hsveread thi.appliatbnand statethallhesbove Information
G bconect.l agree to compiywlth all city and county ordinances and gate laws PERMIT ISSUANCE FEES PAID:
>. relating to building comtmauthorise
ction,and hereby representatives ofthb
N
F— city to enter upon the abovcnnrruorad property for inspection purposes. ALTFRORADDTOMECH.
? (We)agree to save,Indemnify an d keep harmless the City of Cu pert trap Date ReCel t#
against liabilities,ydgments,costs and expenses which may In any way acme AIR HANDLING UNIT OD 10,000 CFM) SUBTOTAL:
against said City in consequ once of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signaurc of Appllcant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applia rat orfutum building occupant atone or ha rad to haaardou. HEATING UNIT(M 100,000 RTU) Date Recei tN
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code ion 75532(a)? HEATING UNIT(OVPR 100,000 BTU) TOTA
❑ Yea No
Will the applicant Rture building Occupant use equipment ordevices VENTILATION FAN(SINGLE RF57D) ISSUANCE DATE
which emit Ian rdous ab contaminants as deemed by the Bay Area Air
quality Management District? BORER-COMP(31 IF OR 100,100 gill)
/Yes f;?tfJo }I
have read lhehaxfrUous materials requirements under Chapter 6.95 of BOILER-COMP(OVO(100,000BTIA
the California I lealth h Safety Code,Sections 25505,25533 and 25536, 1
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECFI. SQ.1'r. JUI� 17
responsibility to notify the occupant of the requirements which swat be met 'a
prior to nceo aCertlfiateo(Ocavpancy.
Gil u N M
Ov6eeror authorired agent Date TOTAL: ISSUED B
OFFICE COPY