23747 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pra'ea Identification F PERMIT NO.
Building Address: 1 A — > L 23747
11ho t A A/9� ne CITY OF CUPERTTNO-BUILDIN SIGNAloha
co ractor'sName: ue.No: APPLICATION /P IT
1 BUILDING-E.EC TRIC AL-PLUM NG- � HAMCAL CATEGORY CONM
qW Architect/Engineer. LIc.No:
SrQ91_5.{,__ Cn. 5b 0.1/sI ^ Qct ELECTRIC P rI' FEE BUILDING PERMIT INFO
Addrma LpIS IyICl/r QY �q PERMIT ISSUANCE LU
LICF.NSF.D CONTRACTOR'S CLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commenc- AP 'NITRE JOB DFSCRll'I'ION
'ngwlthS ion7000)of DiWgon3ofthe Bugnemand ProfessionsCode,and my P ��
Jim.is In full fg(ce and effect. /syr
LicensePass,—)>_Lic.N Iz 3L&
Dateg L Contractor S DECT. R_ L Zola AMT'S J
ARCHITECT`S DECLARATION OVER1000AMPS SQ.FT.FLOOR AREA S/SQ.FL
oc' I understand my plans alu8 W used n public records.
Od0C, b� 6_
Licensed Professional SIGNSELFJCTRICAL
6 OWNER-BUILDER DECLARATION
SPECIALCERCUI7/M1SC
F 7 owinghereby avermthat lamexempt from
essa Contractor's License Law fort he
09� (ollowingreason. SRIon7031.5,BminevandProfesalonaCode:Any dtyor Tp�pMETER OR OLEiNST. T ER
P fats countywhich rcqulresa pemdtroconstruct,alter,improve,demolish,orrepsir
�Y anystmMmpriertulmL ancgalsomquimstheappUmntforsuchpemdtto POWER DEVICES
C file a signed statement that h Is licensed pursuant to the proBlom of the
SFF�5S,, Contractor's Liceren lChapter
9(commencin with Section 7000)ofDivi.
"'30�n Mona ofthe Business and Professloru Code)orthatt he is exempt themfromand as To
SWIMMING POOL ELECTRIC VA
the lauds;for the alleged exemption. Any violation of Section 7MLS by any ETSSWITCHESFIXTURFS /aPvs'
60n applicant for a permit subjects the applicant to a civil perulty of not more than V
tj five hundred 9, dollars(S500). NEW RESIDENTIAL ELECTR_ _ .FI'. 'SQ STORIES TYPE CONSTRUCTION
[:]I,as owner of the Property,or my employees with wage as there sale
compensation iSec.7 , ited.cthworkandionst ucture Code;The
Intended aroffered for
��p sale(Sac.7004,8uslneas and Professions Code:The Contractofe License Law
does not apply to an owner of property who Wilds orlmpruvesthemon,and OCC.GROUP RIS.UNITS
whodoessuchwork himselforthroigh hisown employees,provided that such
Improvements are not Intended oroffered forsale.If,however,thetullding or
i proverrent bsold wllhinoneyearofecmpletion,theovner-bullderwlll have
LT—Ver,ben of pmvmg that he did race build or Improve for purpose of sale.). QTY. PLUMBINGPERMIT FEE FLODD ZONE APN
L�L as net of the property,am exclusively contracting with licensed PERMIT ISSUANCE �e
mntracton to construct the project(Sec.7014,Business and Professlom Code:
The Contractor's License law does not apply to an..or of property whoall ALTER-DRAIN 4a VENT-WATER(EN
Wilds or Improves thereon, and who contram for such pRojects with a
c.�..t{aeme(s)Ucenxd pursuant to the Contractor's License Law. BAIX FT.OW PRDTFLT.DEVICE FEE SUMMARY
Ll I am exempt under Sec B A P C for this mason '
O.v Date DRAINS FLOOR ROOF,AREA,COND. SANITARY RF-CERT M
WOR KMAN COMPENSATION DEC"RATION FIXTURES-PER TRAP SCI{OOL TAX Y_ N_
❑1 hereby af(Irm that 1 have a certificate of consent to m141nure,ora BE =If
rtlflceeeofWorkeri Compensation lreurana or a certlRed ropy thereof(Sec. GAS WEA.SYSITM-1 INC OUTLETS PARK FEE Y N
p ,Lab CJ RECEeT M
Potty a GAS EA.SYSTEM-OVER 4(EA)
Com any BUILDING DI VISION FEES
�CertlBed copy b hereby fumishM. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCIIECK FEE
❑ Uln
Certed copy Is with the city Inspection lon division. Q
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM 200F1' DaIC RCCCI I#
(this section need not h completed If the permit b forone hundred dollars
(5100)or lent') WATER HEATER W/VENT/ELECTR71 ENERGY FEE Y_ N_
I certify that In the performance of the work for which this permit Is owed,
I shall not employ any person in any manner ro as to become subject to the WATER SYSIAI/TREATING PAID
Workers'Compensation Laws of California.Date
O Z Applicant NEW RESIDENTIAL PLMB. SQ.Ff. Date Recei t#
Z O NOTICETO APPLICANT:ILaher making this CCrtRleate of Exemption,you
Fshould Wcorrcaubjeet to the Workers'Compensation prevbiomof the Labor TOTAL: ,S
W Code,you must forthwith comply with such provisions orthls permit shall BUILDING
IY j deemed revoked.
IL — coNsraucrloN LlacolNC AGENCY SEISMIC FEE
CL e Iherebyaffirrnthat there eacomtructlon lendingagency forth perform- ELECTRIC FEE �+
M Z ante of the work for which this permit is Issued(Sec.3097,Civ.C) C0 PLUMBING FEE
02 Lender's Name TY. MECHANICAL PERMIT FEE
U. F Lenaera Aaareaa Q MECHANICAL FEE
U IceNfythat l have mad this application and aatethatthe above information �� t
O W bcomect.I agree to comply with all city and county ordinances and gate laws I'ELNIT155UANCE FEES PAID:
> a relating to building construction,and hereby authorize representatives of this '1
t• Z city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH. tel.
_ Date ReceiF[#
(We)agree to save,indemnify and keep harmless the Cu m
V
against liabilities,judgments,costs and expenses whit yin in any wayacme
AIR HANDLING(IMT(TO 10,0D)CFM) SUBTOTAL:
sgMIgo Id City JpeawegwKo(the an' gofe s rm ,
w C� AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTIONTAX
Slgwumof Appeont/Contra or to EXHAUST HOOD(W/DUCT)PV CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wllllheappecant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 OTU) Date RCCCI t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
HrA h and Safely Caderr.�Section 25532(s)2 HEATING UT(OVER 100,000 BTU) -
❑ Yes u No
Will the applicant orfuture building oceupantuse equipment ordevices VENTILATION FAN(SIN, RESID) ISSUANCE DATE
which emit hazard..,air contaminants as defined by the Bay Area Air
Quality Management District? BORER-COMP DHP OR 100,000 BTU) R p
❑Ym 1F—�11 No IC((9 A B D
I have read the hazaM.,materials mqulrements under Chu Enter 6.95 of BORER-COMP(OVFR 100,000 BTU)
the California Health 6 Safety Code,Sections 25-%5,25533 and 25530.1
and crsta rad that if the build Ing does not cut mently have a tenant,that it b my NEW RESIDENTIAL MECH. PO.FT not^ 7
m �^
responsibility to notify the occupant of the requirmants which must be et
prior to Issuance of a Craffirate of Occupancy.
nrlY 1,,r cnUlvt.
Owner or aulhori dagent Date ISSUED
IOTA
OFFICE COPY