23834 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro act Identification - PERMIT NO.
Building Addreas: 23834
67
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/1'1 CITY OF CUPERTTNO-BUILDING DIVISION
C.ntrxt rName1• Lk.No:' APPLICATION /PERMIT !e
s L_ BUILDING-ELECTRICALPLUMBINGMECHANICAL CATEGORY CONTROL#
AreMtect/Engineer. Llc.No:
BUILDING PERMITdNFO
��/
QTY� ) ti ,ELEIZTRIC PERMIT t�i ,'�11) ,y FEG p. rt.+�; al. .
Address: �1 �� �Q�js70!/ � ��'� 1'FRh9TIS5UANCE .
LICBNSEDCONTRACTOR'SDECLARATION qj 0
]hereby offirm that l amlkensed under prxwEconsof Chapter9(mmmenc- APPLIANCESRESTDENTTAL OR)FSC N �
Ingwithlefullmensand efelon3oflhe Buslnnsand Professions Code,andmy L L le
Ilmnse Is in full(ora and d(ttt. - PANELS
Llme.Class Lies
Date . Contractor
ARCHITECT'S DECLARATION 701-1000AMPS
_
p�++NO Zpp l understand my plana ehae be used as public mcoNx OVER 1000 AMPS -
SQ.Fr.FLOOR AREA a/ .FL
Fi�(3 Licensed Proleed..) SIGNSELECTRICAL t ,�
L 6 W OWNER-BUILDER DECLARATIONJ'i I� E 1) 1 N
1 SPECIALCIRCIllT/MISC ,,,� 7 0
`Z��4 owingrason.(hatlamexempt31.5,B fromthe Contractor'sLicenseCode:Law fort he \
pp�rs fauntyW ices.nutrusa ermitw easiness and Professions Code:Anycityor t�� L� � if `� 5� r_`
countywhich requlrcsa permitromnstrotl,alter,Improve,demolish,orrepalr TEMP.METE20R POLE]NST. �-+1 4L II'�III/
any structure prior to its Issuance,also requires the appileant for such permit to POWER DEVICES / J
(Ile a signed statement that he Is licensed pursuant to the provisions of th
O e
01,t', Contractor's License Law(Chapter 9(mmmencing with Section 70W)of Divi- SWIMMING POOL ELECTRIC
SOS eI..3ofthieusiness and Professlons Code)orthat he b exempttheretromand - -
< the basis!or the alleged'exemplion. Any violation of Section 7ell.5 by any OUTLETSSWITCYMSFIXTURES
applicant fora permit subjects the applicant to a civil penalty of net more than
�j NEW RLSIDEMIAL ELFLTR SQl7.
live hundred dollars($500).
Q ❑Lasowneroftheproperty,ormy employeeswithwagesas thelesale. STORIES .'IYI'E CONSTRUCTION
compensation,B..I.s hework.andthest Code:um The
notIntendedor icanse Law -
$ ❑ sale(Sec.70Kpply Businesserf property
who
W ills Contractors Llanu Law
docs not apply man owner of property who bunds er improves thennry and uch OCC.CROUP RES UNITS
GG
who doessuch mentsa not Intel!or edormgh his own e.If,ho a proer,theedthat gor
Improvements ithindneyear(erect(oraale.ILhoweveg deer ilI have 'p �/
Improvemen[bsold within.neycarofmmpldlorytheowner-bullderwiil have . -
I ^Isrdeno(pmvingthm he did not build orlmprove for purposeolsals.). QTY,'„ i" PLUMBING PERMIT`S' '' j„'FEE ;' FLOOD ZONE APN
U L as owner of the property,am exclusively contracting with Bmnsed ppRMITISSUANCE '
contractors to construct the project(Sec 7044.Business and Professions Code:
The Coetnctor's License Law does net apply to an owner a property who ALTER-DRAIN kVENT-WATCR(EA)
Wilds or improves thereon,and who contracts fee such ptu)ects with a
cIffctor(s)licensed pursuant to the Contracx tors LlanLaw. '.u' p 'r`"FEE SUMMARY •?
I_f I am exempt under Sec. B k P C for this reason BACK FLOW PROTECT.DEVICEOUTSIDE FFFq
_
OwnerDRAINS FLOOR ROOF,AREA,CON). SANITARY Y N
Data
- RECEIPT M
WORKMAN COMPENSATION DECLARATION FIXTURF_S PER 77LVr SCHOOL TA% Y N
I]1 hereby affirm that I have a certificate of consent to self-insure,ora RECEIPT N
ceAlfioteof Workers'Comper tionleauranmoramniflcdropythe=f6ec. GAS EA,380,lab C.) PARK FM Y_ N_
Policy p GAS EA.SYSTEM-OVER4(EA) (RECEIPT If
Com any BUILDING DIVISION FEES
MAIfled copy is hereby furnished. CREASE/INDUSTRL WASTE INTEIRCI•I'TOR PLANCHECK FEE
MCertifted copy b filed with the.ary Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE - SEWER-SANITARYSTORM EA 700Fr Date Reml ttf
(rhissectlon need nod be completed If the pertNt V forone hundred dollars
(SI I0)orfess.) WATER HEATER W/VENT/ELECTR ENERGY'FEE Y N—
I
that in the person
oninaumor ny Wonerhe work su as tobcomthis ermltct is to the I shall not employ any person In any manner m m to become subject to the NEW RESIDENTIAL PLMR. SQ.ET. Date Remi t#
0 WATERER SYSTEM/TREATING
Workcre'Compevatlon Laws of Cali(omW.Date ,PAID
Z NOTICE
Z'a NOTICE TO MPLICAM:Il,oiler making this Certificate of Exemn,plloyou
should become subret to the Workers'Compensation provisions of the Labor TOTAL:
N Code,you muatFort hwith comply with such provisions or this permit shall be BU
j deemed revoked. BUILDING PEE
W CONSTRUCTION LENDING AGENCY SEISMIC FEE _
CL Ihembyaffirm that there b a construction lending agency for the perform- ELECTRIC FEE
Z anmof the work(.,which this permit b Issued(Sec.3097,Civ.C.) TOTAL: �J
U O Lenders Name PLUMBING FEE
LL H Lenders Address - QTY. MECHANICAL'PBRMIT'; '.t;FEE I MECHANICAL FEE
O I ceutifythat l have read thisapphationand state thattheab.ve Information
W is correct.I agree to comply with all city and county ordinances and sate laws PERMIT ISSUANCE FEES PAID:
>. 0. relating tobullding construction,and hereby authorize representatives ofthis
F Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECFL _
— (Wa)agree to save,Indemnify an If keep harmless the Cityof Cu rim - Date Receipt#
gaineruld cu liabilities,pd s,cose
costs and expands wh a vYin AIR HA NDLING UNIT(TO 10,000 CPM)
.go t C in a enthe gr firing oft rmSUBTOTAL:
ER000
it♦�w
�u AIR HANDLING UNIT(OVIO, CFM) CONSTRUCTION TAX
i3'gnature of Applicant mvctor Data EXHAUST HOOD CONSTRUCTION TAXPAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appllant orfuiure bu Bding occupant store or ha nd Is haeardous HFATING UNIT CM 100,000 BTU) Date Recei tit
as deft rad by the Cupertino Municipal Code,Chapter 9.1 7,and the
Health and Safely Code Section 75537(a)7 HEATING UNIT(OVER 100,000 BTU) - IOTA I�r
❑Yes u No
Will the applicant or future Wilding ocmpaat use equipment ordevices VENTILATION PAN 6INGLE RFSID) ISSUANCE DATE
which emit hazardousair contamimntsasciefined bythe Bay Area Air PAID Quality Management District? BOILER-COMP OHP OR 100,0()BTU) P
, I Yes (�No
haverthe bozo .ua Rsierlars requirements under Cha picr 6.95 of BOILGR-COMP(OVIiR 7(10,0008111)
the Californiala Heahh k Safety Code,Sectio®75505,25573 and 75536.1 JUN 15 199
understand that if the building does not currently have a tenant,that It is my NEW RLgDENTIAL MECH. SQ.FT 2
responsibility to nalfy the occupant of the requirements which at be met '
prior to issuance of Certificate o(Occvpanry. - C14YUr LUNthIIIYI� '
Owner or authorlead agent - Date -
TOTAL: ISSIIEDBR�� _
OFFICE COPY
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