23155 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Bultdin project lJentlflntlon PERMIT NO.
Building Address: 23155
ncr one:
..� _ CITY OF CUPERTINO-BUILDING DIVISION
Contncfora Name: Lic. o: APPLICATION /PERMIT L.a
�� Hr, BUILDINGELECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL If
Architect/Engineer. Lic No:
QTY ELECTRICPERMFF FEE -BUILDING PERMIT INFO
Addreac ` PERMITISSUANCE F-1 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(mmareac. APPLIANCES-RESIDENTIAL ]OB DFSCRIPHON
ingwith Se on7000ofDiWgm3oftheBusin and ProfeWonsCode,andmy �a UN
hones Is In W11 to.and died. PANELS
Llanx Class Lk.N REp,�[�z - ^ --�`(P�
Date Contractor it. ff 1�CT-/
ARCHITECTS DECLARATION 201-1000 AMPS
N2 I undenrynd my Pla�haBbeyeadu blpF Icremnls OVERI000AMPS SQ.FT.FLOOR AREA $/SQ.FT.
5 Licensed Professional ` — SIGNS ELECTRICAL �!'L E
<
OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC n nER
fur Pa '7 owingraf@mthatlam31.5,BfromtheContofessiosice.Code: nycityawfor he followingresson.iresap 7WL$Business and Professions Code:Mycity itO TEMP.MEIIIt OR POLE INST.muntywhlrh requlrnaperMttomrutruc,alter,lmpmve,demolhh,orrepalr
any structure prior to its luuance,also requires the applicant for such permit to POWER DEVICESE
ry1 file a signed statement that he t llansed pursuant to the provisions of the
Contractor's License Law(Chapter 9(mmmencing with Sector,7000)of Divi- SWIMMING POOL ELECTRIC 30 VALUATION sion 3 of the Business and PodesslonaCede)artha he is exmpttherefem and
the basis for the alleged exemption. Any violation of Section 7MLS by any
p applicantfora permit subjects the applicant to a civil penalty of not more than OI1TLElSSNTTCFIE5FIX3VRE5 00-00five hundred dollars(B50%.
E]1,I,as owner of the property,or my employewith wage as there NEW RESIDENTIAL ELECTR sole SQ'FT' STORIES TYPE CONSTRUCTION
compensation,Ike770K
Einess do wok and theProfessions Codure t not IntntraMed or coffered for
salq doe not apply
to an owner of property
who builTheds
Contractors License Law
g doesnotapply torn owner ofpropertywhonemporImprovesthereon,andwho OCC.GROUP RES UNITS
impnav asuch mentswork Intended
orthrougedmoff. clsowne.If,ho eprovWedthatauch
improvement are am Intendedearofcd(weak.lis,h nee thebildiag or have Tp7pL;
improvemenitaoldwlthln oncyearo(completbrytheownervbu0derwillhave
the burden of preying that he did not build or improve for purpose ofsale.), Q7y, PLUMBING PERMIT FEEFL 1)zONE APN
u[as owner of the property,am exclusively=trading with licensed pggMR ISSl1ANCE
contractors to construct the preject(See.7044,Business and Professions Code:
The Contractors License Law dm not apply to an owner of property who ALTER-DRAIN&VENT-WATER(PA)
builds or Improve thereon,and who centnp -
cts for so&
projects with a FEE SUMMARY
,0I(+ctor(s)liarucd pursuant to the ContnctaiLloenx Law, BACKFIAWPROTFCT.DEVICE
LI,am am exempt under Sec B h P C for this...
OwnerDate DRAINS-FLOOR ROOF,AREA,COND. SAMTARY Y N_
RECEIPTN
WORKMAN COMPENSATION DECLARATION PER SQi00L TAX Y_ N_
[31 hereby affirm that I have a certificate of consent to self-insure,or FIX'NRFS RECEIPT
mdiflmteof Worker'ComperuationlruuranmoramAifiedmpythereof(Sec.
3800,Lab C.) GAS FA SYSh2H 1AICA OUTLETS PARK FEE Y N
P.iky N GAS-EA.SYSTEM-OVER 4(EA) RECEIPT X
Ceny BUILDING DIVISION FEES
omElCertified copy thereby(Badwth the city CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
El Certified espy t filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANRARY-STORM EA 20UFT Date Recei t#
Rhisees.) need eat be completed I(the permit t(ororu kande ddollen
(SIOOJorfy that
WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
Icenot thato the person
manhe ner
an as tobeco permit lc to theed, —
I shall not employ any person t any manner n ss to become subject to the WATER SYSTEM/TREATING
Workers'CompensationlAsys of 6Bfomla. Date PAID
O Z NOTICE
NEW RESIDENTIAL PLMB. SQ.Ff. Date Recti t#
Z O NOTfCETO APPLICANT,If,after making rs Compensation
sationlprev Exemption,you
CC ande,youould =atforthwith
it the Waken'Compewtlonprovhis permit
shall
TOTAL-
CC
f/2 dermad
yoked.rthwilh comply with such provisions or this permit shall be
] deemed revoked. BUILDING FEE
LU CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Thereby afBrmthw there tacomitIs bonlendingagency for the perform ELECTRIC FEE
7 Z once of the work`2.t this permit Is Issued(Sec.3097,Cn,Q TOTAL PLUMBING FEE
U O Isnder'.Name
IL F Lender's Address ceQTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I rtilythat l have read thtapplicatlonand atawthat theabovelnformatlon
0. tcorrect.I agrecto comply with all city and muntyordinances and slate laws PERMIT ISSUANCE FEES PAID:
�. W relating tobuilding construction,and hereby authorrcpmantatives oftht
Z city to enter upon the above-mentioned property for inspection purposes. ALTER ORADDTO MECH. Date Receipt#
— (We)agree to save,Indemnify an d keep harmless the City of Cupertino
against liabilities,Pcigmsnt,mks and expenses which may In anywayaccue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City In consequence of the granting of this permit. AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZAA7ARDOUSOUS MATERIALS DISCLOSURE '
Will the applicant or towns building occupant store or hared to harardous HEATING UNIT(TO 100,=BTU) Date Receipt#
material as defined by the Cupertino Municipal Code,Chapter 9.1Z and the
I ealth and Safety Code Section 75532(.)7 HEATING(TMT(OVER IM,000 BTU) TOTAL:
Rill
�]No
RIll the applicant or future buildingomp.at use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hasardous air contaminants as defined by the Bay Area Air
Quality Management Dlstdct7 BORER-COMP GIIP OR 100,000 BTU)
4Yes ❑No
haveread the barsgusnuterialsrequiremnt,underChapter6,95of BOILER-COMP(OVER IW,000BTU) IPA
the Coliform Licxlth bSafety Code,Sectione25lyh.5573and755M.1 "B" Pq B
undentandyto if notify
thlding doe not erequiy nand.which
that lttmy NEW RESIDENTIAL MECH. SQJR
repomibiu Issuance
of aCr a cats of t rmpa requlrcment which must be rM I ar� O�
Prior to tsuana cats Certlfkate of Occupancy. � JAIII
Owner or authorized agent Data .. ISSI fJy /JJ4
TOTAL: bb''BBYY
OFFICE COPY