23203 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
-Building Project Identification PERMIT NO.
BuBame 72Addresw6�'t� Z 3• �t 23203
wne/��t�N : one;
IYL. 7y�••L��I Z 4Qlat CITY OF CUPERTINO-BUILDING DIVISION
Contractor's Nara: ' •w , Lie.No: APPLICATION / PERMIT
BUILDINGELE)CDUCAL-PLUMBINGMECHAMCAL CATEGORY CONTRO(.a
Architect/Engineer. Lie No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ ❑ ❑
LICENSED CONIAACder pr DECLARATIONprovisions
wfthSc ion700).lamllcm3.fth. erprevldaveoe Chapter9(ie,and APPLIANCES-RESIDENTIAL JOB DESCRIPTION
tngwehSMlon 7000)ofd ddon3o(the Budriessand Pro/eWonsCode,and rs
I 11«nee la In full force and died. PANELS /� �^
License Class a- iib LIc.N I(/ 1 .'�
I-17-GIT ConhaiarUP TO 200 AMPS
ARCHITECT EC k ATION 201-1000 AMPS
re 0N O I understand my plans shall he used as public recrrds. OVER 1000AMPS SQ.r.FLL ' S/SQ.Fr'.
Karl Licensed Preef Lural SIGNS ELECTRICAL 1 /^\\, P I
6 i, OWNER-gNLDER DECLARATION SPFG7ALCR(CUIT/MISE `3 /� aEF
17F, thereby affirm that Iam exempt fromthe Contractors License Lw for the 4V V
09 Epp countygreawn.(Ses apritt.B.muceand Proteelons Code:Anycttyor �
I rountywhich requiresa permit tocontmct,altep Improve,dermllah,urrepalr TEMP.METER OR POLE INST.
anystructure prbr to its iwance,also require the applicant(or such permit to
rel file a signed statement that he is licensed pursuant to the provisions of the POWER DEVICES E
O u,l• Contractor's License law(Chapter 9(mmmene ng with Section 7000)of Dlvl-
�O sion3 ofthe Businessand ProfeakreCode)orthd he le exempt therefnemand SWANh9NG POOL ELECTRIC VALUATION
o the basis for the alleged exemption. Any violation of Section 70315 by any OUILETSSWITCHESE%IURES
applicent fon
permit subjects the applicant to a civil penalty of oat room than
five hundred dollars(8500), NEW RPSIDENTIALELECIR
I,as owner of the co eITOTAL:
STORIES TYPE CONSTRUCTION
ucmp� p p rty,or my employee with wages r their sole
7 Q as V(Se ea 0Kwillinesdo work Peafes Chest ode:Th not intended or offeredLaw
❑ sale(Sec.apply
to Business f putpeion Code:The u lids or impctoJs U«rue Lw
S$ does net apply torn ownerofproughrty who nempoyees,pvvted me,that and OCC.GROUP RIS.UNITS
whoducaprovemcs work amnotlmsededoroughNeow ale.If oweerthedthatsuch
improvements am i ithinaedearo(cdfor eale.If, mner-q gofer ilI have ImprovemenHawldwltMn oraycarofcompldlon,theownerbudderwlllMave
OW-1lurden of paving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERFEEpLOODzoNE APN
Lf L as owner of the property,am exclusively contracting with licensed PQ2MLI,ISSUANCE
rontractore to mrutruct the pmjcd(Sec.7064,Business and Profession,Code: �•
The Contractors Lt..law don nut apply tom owner of property who ALTER-DRAIN k VENT-WATER(Eck)
bailie or Improves thereon,and who contracts for for such inpjecwith a
c Lf I
ffdor(s)licensed pursuant to the Contractors License Law, BACK PLOW PROTECT.DEVICE FEE SUMMARY
am exempt under Sec. B k P C for this reason
Owner DRAINS-FLOOP.ROOF,AREA,COND. SANITARY Y N_
Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP 0 SCHOOL TAX Y N
❑1 hereby affirm that I haves [mum a of consent to self-Ineu«,ora V RECEIPT N
380cort0,Labfleate of Worken'Compewtlonlnunnce ora«nifled coPY thereof(Sec. GAS EA S-YS EM.1 INC.4 OUTLETS
Polis[ab CJ PARK FEE Y— N_
Policy N RECEDING DT M
S P.A.
Com GASYSTEM-OVER d(EA) BUILDING DI VISION FE ES
ertlfied copy is hereby te
Cenifled ropy V tiled withh the city
Inpectlon division. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
ity
CERTIFICATE OF IIXEMPTION FROMWOR HERS' GRWETRAP PAID
-
COMPENSATION
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA MOF[. Date Recef t#
(TM1isctlan need not be complied If the pemJt V for ane hundred dollars
(8100)«fy that
WATER HEATERW/VENT/ELECTR ENERGYFEE Y N
I«note ploy any pe n i anyt nnerworwf. which this permitvpa to theed, —
I,hail not employ any perws In any manner at u to become subject to the WATIR SYSTEM/TREATING
Worken'Compensanon laws of California.Date PAID
C' Z Applicant
Z O N'OTICETO APPLICANT:[,after makingthIxCertlflatsof&emptlon,you NEW RL9DENTIAL PLMB. SQ.hT. Date Recet t#
F should become subject to the Workers'Compereatlon previelonofihe Labor TOTAL:
N
Code,you=at forthwith comply with such provlsimes.r thla per al hall be
> deemed revoked. DING FFG
W
—p
CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z Ihembyaffirm thattleeels construction lending agency for the perform- T ELECTRIC FEE
and of the work(or which tM;permit 1,issued(Sec.3097,Cie.C.)
V O Lenders Name PLUMBING FEE
ly — Lndeea Addama QtY. MECHANICAL PERMIT FEE MECHANICAL f EG
O W 1 mdifylhat l have read lhisappllotam.ed Yatethatthe above infomation
1 IecomR.Iagreeto complywlth all cityand county ordinances and data law. PPRMITISSUANCE FEES PAID:
} W relating to building cmatructlon,and herebyauthoriza representative,ofthls
I— Z city to enter upon the above-mentioned property for Wpectlon purposes. ALTER OR ADD TO MUCH.
(We)agree to save,Indemnify an d keep harmless the City of Cu pen leo Date Receipt#
V
against Tlabllitles,judgments,"a and expenses which may In my way accrue AIR HA NDLING UNIT CrO 10000 CFhB SUBTOTAL:
.g.inst,mald City in con ens of the Sooting oft Is permit AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
/ L
Sruture Appl /Contractor Detc IXIIAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicanteft.edb the Cupertir futum no
ng Murldpl Cod, hhandle 9.IZ ahazardous HEATING UNIT(TO 1fD,fgO BTU) Date Recel t#
materialas Safety bythection2no Munlctpal Code,Chapter 9.12,and the
T'Iealth and Safety Cade Stolon 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL
Yes 1rN No
Will the hamedeorrNoses buildingcontaminants
occupant use equipments devices VP.N'IILATIONPAN(SINGLE RESID) ISr TjE,DATE
which eManaement air contaminantsaedell ned by the Bay Area Air PQ'+ (p�6 II I4/
• Quality Management District? BOILER-COMP(3}I+OR 100,IX0 BTU)
4Yes '2 No
havcreadtheb. ousnutedalarequirementsunderChapter6.95of ROILER-COMP(OVER 100,000BTU) assn' q g9n)
the Calitomia Health&SafetyCWe,Sedion255e5,25D3 and 25536. 1 JAN 1 1 JL
understand that if the building don not currently have a tenant,that it le my NEW RESIDENTIAL MECH, SQ.Fr
responsibility to notify the occupant of the requirements which must be oat CITY Vr (aU('tT11 tIVV
prior to Issuance of a GnlRate of Ottvpancy. ����ss......����....,,��....
Owner or authorirea agent Date ISSUED BY1�
TOTAL:
OFFICE COPY