23666 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
goBuilding Project Identification PERMIT NO.
]ding Address: 23666
w ante: - - one:
/40 SD$%,f CI TY OP CUPERTINO-BUILDING DIVISION
. c°"tracta Name: Lm No• APPLICATION / PERMIT
J BUILDING FELFCTRICAL PLUMBING-MECI IAMCAL CATEGORY CONTROL p
Archanct/Engloeer. Llc.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:
PERMITISSUANCE7-1 ❑ Lp El
CONTRACTOR'S DECLARATION
Ihereby
ection that7000)o DivisIs. ensed 3 oftheerpassand so(Cusions9(commene- APPLIANCESRESIDENTIAL JOB DESCRE'710N
In ease i Section 7D00)af d offeon3 ofthe Bualnssund ProfessloneCode,and my
license le in(uLL and sited. r PANGS
Licen ^a® =
Dat mmLmm J 1
acm,ct°r �J t,
ARCHITECT'S DECLARATION 201-1000 AMP"'
NO$O I understand my plaza shall be used u public reorda OVER 10DO AMPS SQ.FT.FLOOR AREA S/SQ.FT.
zE Licensed Professional SIGNS ELDC UCAL yy��
q�"v13 by OWNER-BNLptDER DECLARATION SPECIALCERCUIT/MLSC IP�, ® g�1 1
vr:{ ]here a(Brmthall am exem fromthe Cont.d.esLlrenre Law(orthe I� V
pp following reason.(Section 7031.5,Business and Professions Code:Any city or r �' � T5N
Zcountyires TEMP.METER OR POLE INST.
� u anystm which rtotape M ,,.L troct,alter,imppHuntf rsuch,er tto
U any atmctedsatirtolt that he
aco sed pursuant to the rewbiom of to POWER DEVICES L'J�
r� V file a signed statement that M U licensed pursuant to the provislona of the
p�2�jj Com.d.e.License taw(Cha(Chapter 9(commendn withSection7000)ofDivi-
p pt B SWIMMING POOL ELECTRIC
aion3ofthe Buelnneand Professlona Code)orthat hebexempttherclromand TI N
< the basis for the alleged exemption. Any violation o(Settion 70315 by any OUTLETSSWITCFRSFIXfURES
applicant fora permit subjecutheapplicanl to a civil penalty of next more than
five hundred dollars($5D0).
NEW RESIDENTIAL ELECTR_SQ.FI',
❑I,asownerof the property,or my emture 1nwithwages r theirsole STORIES 7YI'ECONSIRIX:nON'
compec.70 ,wWdothe work.and the,Code:
1,not Intended orofferedfor
Oale(Sec aptly to a nese and f property
Code:TM.,intp Roes untrue law
does net apply lorkhm r ofppxxrghwhonemporimproves ovided that such
OCC.GROUP RES.UNITS
whodoeseuchws,nor] to dedor°ughed owns.If,ho however,
ebuildiouch
Improvementsarenotintendedoroffc.mplfor sale.the owevep deer building have TOTAL:
Imppoverrent avoid wilhinormyearo(compleibn,theowner-bullderwlll have
the poen of proving that he did not build or improve for purpose o(ule.). QTY. PLUMBING PERMIT FEE
I,as owner of the property,am exclusively contracting with licensed FLOOD ZONE APN
contractors to construct the project(Sec 7061,Business and Professions Code: PERMITISSUANCE
The Contrector's License law does not apply to an owner of property who ALTELDRAW Is VENT•WATER(EA)
builds or Improves theorems,and who contracts for such Pjetts with a
JadWI licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
L_J I am exempt under Sec. B &P C for this reasonOUTSIDE FEES
Owner DRAINS FLOOR ROOF,ARRA,COND. SANITARY Y N
• Date RECEIPT N
WORICNAN COMPENSATION DECLARATION FDGURFS PER TRAP SCI10OLTAX Y N
❑I hereby affiren mkm%that I have a ce surer mof consent to opythapoo ora RECEET N
artiflcate o(Worken'Comperwtl°nlnaurance oracertllled copytheranf(See. GAS FA.SYsmw INcd OUTLETS
3800,Lab CJ PARK FFR Y N_
Policy N 3 RECEIPT N
Com anv GAS FA.SYSTEM-OVER4(EA) BUILDING DIVISION FEES
�Certifiee'ropy is erc�th thehed.
CeCREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy V tiled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE
(Thlssection need not becompleted tithe permit isformshundreddollarc SEWER-SANTTARY-STORM EA.200FT. Date Recei III
($100ertifyha WATER I[EATER W/VENT/E.ECTR ENERGY FEE Y N
]certify that In Ne performance o(the work for which this permit is Laaed, 5e -
I shall not employ any person In any mannerso a to become abject to the WATER SY5rEm/TREATING
Workers'Compensation Laws of Califomia.Dale PAID
Z Z Applicant Date Recel tq
Z Q NOTICE TO APPLICANT:11,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQFT.
should become subject to the Wurkers'Comper satlon provisions of the Labor TOTAL:
N Code,you at forthwith comply with such proWlors ar this permit shall be
j deemed revoked.aCONSTRUCTION LENDING AGENCY SEISMIC FEE
I harebyaf(inmthat there is a construction lending agency for the perform - �1.� ELECTRIC FEE
Z ante ofthework for which this permit is Issued(Sec.3097,Civ.C.) TOTAL:
U O Lender's Name PLUMBING FEE
IL I— - Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O 111
Imrtlfythatlhavereadthbappliratbnendstalelhattheabovelnfortwtlon
IL iscorrect.l agree to complywilh all city and county ordinances and elate laws PERMITISSUANCE FEES PAID:
>. N relating to building mretructlon,and herebyauthorlurepresentativeso(thio
~
Z city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH. Date Recei t#
_ (We)agree to save,Indemnify an d keep harndew the City of Cu portion
against liabilities,judgments,"a and expenses which may in any way accrue AIR FIANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
ag7uld City In ronsspuenm of the granting of this permit --
y / AIR HANDLING UNIT(OVER IO,ODOCFM) CONSTRUCTION TAX
SI Nroof Applicant/Contractor Data E(HAUSTHOOD(W/DUCn CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willtheapplicamorf w.buildingocrupantstoreorhandleh.z ,dous HEATING UMT(TOI00,000BTU) Date Recei tiff
as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
Iie❑alt Y nd Safety Codc Sectlaon 25532(a)? HEATING UMT(OVER 100,060 BTU) TOTA
Will the applicant or fu❑ture building occupant use cqulpmant or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havrdous air contaminants as defined by the Bay Area Air
. Quality Management District? - BOrLERCOMP OIR'OR 100,000 BT(n
Yas ❑No
have read the hazalloue nulerlab requBOILEER
lroments under Chapter 6.95 of R.COMP(OV100,000 BTU) f0�a�
the California Health&Safety Code,Sections 25505,25533 and 25534. I L" t B
understand that if the building docs not currently havaatanant,that It is my NEWRISIDENTIALMRCH, SQ.FT. 9 N
responsibilityce notify theicapantoftherequlremente which must be met ®C�\\
prior to Issuance of iytheo cu a tomhe roq
Owner or authorlaed agent
Data ISSUIrU UYr
TOTAL:
OFFICE COPY