23859 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Budd Ing Add hnme. 23859 '
71; ere /aces: one: A
n /C-6hj;7$0Aj :2r/7_09&9CITY OF CUPERTINO-BUILDING DIVISION
¢n tinct ra me: �V N ue.Ne: APPLICATION I PERMIT
Architect/Engineer. Lk.Na BU[I'DINGELECTRICALPLUMRING-MFLHAMCAL CATEGOItY CONTROLp
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address
PERMITISSUANCE 1:1 1:1 ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby aHkm that)am licensed under provisions o(Chapmr9(commne- APPLIANCES-RESIDENTIAL JOB DESC O
tagwlth Section 7000)of Dlvlslon3 ofthe Bokneseand ProfesslonsCods,and my - ^
Rcense is in(ul lorce an effect. pt T.a975 PANELS 007
License Chea s - k.p o49 //__ ll..
Date Contractor I//14,1'JC4 _
ARCHITECTS DECLARATION JJ 201-1000 AMPS
mO Zp� I understand my plans shall be used as public records. OVERID00AMPS SQ.Fr.FLOOR AREA $/SQ,FT.
o(/Licensed Pmfessloml SIGNS ELECTRICAL '
6 OWNER-BUILDER DECLARATION SPECLILCB2CU[T/MISC '
Z,pp., p I hembyaffirm that l am exempt fromthe Contractors License Law forthe
O R f:W following reason.(Section 7031.5,Business and Professions Code:Any city or TEMP.METER OR POLE[NST.
F4 cmntywhlchrequlresapermittommtmc"ter,Impmve,d..IWh,orrepalr
anystmmmpel toitsL ante,alsorequimstheappBcantforsuchpermltto POWER DEVICES
file a signed statement that he Is licensed pursuant to the provisions of the
3�fn Cantractoe.LDs.xGw(Chapter9(mmmmc1ngwlth Sect1on7000)of Divl- SWIMMING POOL ELECTRIC
,.•4 p, slon3ofthe Businenand Pmfenlota CWd )orthathehexempttherefromand - VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any
<
applicant fora permit subjects the applicant to a civil penalty anpt more than OUTLETSiSWITCHESFIXTURES
five hundred dollars(5500), NEW RESIDENTIAL ELECTR JL/
❑I,as owner of the property,or my employees with wages as their sok SQ.FL SCORIES TYPE CONSTRUCTION
compensation,will do the work,and the structure is not intended or offered for -
q sale(Sec.7064,Business and Professions Code:The Contractors Llcerae Law
does not apply to an owner of property who builds or improves therms,'and OCC.GROUT' RES,UNITS
4 whodoessuchworkhi.1f rthrmghhisownemployees,providedthatwch
Improvements are not intended oroffered forsale.If,however,thebullding or TOTAL:
Improvement lssold Mthin oneyearofmmpleioM the owner-bu0derwlil have -
t"[den of proving that he did not build or Improve for purpose of sale.). QTY, PLUMFLppD 7ANE ApN
co
LJ L as owner of the property,am exclusively contracting with Iirenxd PERMrC PLUMBING
BING PERMIT FEE ntractors to ccnstrott the project(Sec.7044,Business and Professions Code:
The Contractor's License Law don not apply to an owner of property who
buALTER-DRAIN&VENT-WATER(FA)
Wild.or Improves thereon,and who contracts (a such projects Wth a
c�R�(acmec,r(s)licensed pursuant to the Contractor'sLkxnse Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under SB&P C for this reason
net Data DRAINS FLOOR ROOF,AREA,CONED. SANITARY Y N_
qq--ss WORKMAN COMPENSATION DECLARATION RECER'f p .n
Lda hereby affirm that I have a certificate of consent to self4rumm,a a FIXTURES PER TRAP SCHOOL 7AX- Y N
certlfiate ofWorkera'Compematlon ox anama certifed copy thereof(Sec. RECEB'Tp
— ( 3800,Lab CJ GAS EA.SYSTEM-1 INC.60UTLEIS PARK FEE Y_ N
{ Policy p�>2f,/ifs / X7.1-, RECEB'r 0
Com any GAS-EA.SYS1TM-OVER4(FM '" BUILDING DIVISION FEES
�Ce ed copy is herefiled w th the
GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
.died copy Is filed with the city Inspection division.
CERTIFICATE OF IXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE
(This section need Am be completed if the permit is forms hundred dollars . SEWER-SANITARY-STORM EA.200Fr. Date ,Recej t#
($1D0)or lent WATER HEATER W/VENT/ELFCTR S ENERGYFEE Y N
I cattily that In the performance of the work for which this permit is issued, —
I shall not employ any person in any manner an as to become subject to the WATER SYSTEM/TREATING -
WOrkem'Compensatlonl ws.f California.Date t PAID
O Z Applicant _
Z O NOTICETO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB.__SQFI'. Date Rn!E!#
should become subject to the WorkersComperaation provieima of the Labor TOTAL:
W Code,you must forthwith comply with such provisions orthh permit shall be
W j deemed revoked. - -
BUIG'FEE
a G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lendingagency for the perform- TOTAL: JC�
O' ance of the work for which this permit i.Issued Tc.3097,Civ.G.) ELECTRIC FEE
(� _ isnder'e Name PLUMBING FEE
LL )— Lender.Addres. QTY. MECHANICAL PERMIT FEE
O W Iced lfy that have read this application and state that the above information MECHANICAL FEE
1 hcorrect.Iagree to complywllh allcityand county ordinances and state laws - PERMIT ISSUANCE PEES_ D;,�
N relating to building mmitruction,and hereby authorize representatives of this
city to enter upon the above-mentlosed property for Impostor purpe s a. ALTER OR ADD'IO MECH. / -L
— (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
against llabWtks,judgments,coatsand expenses which may In anyway accrue AIR HANDLING UNIT fro 10,000 CFM) SUBTOTAL:
ago City In conacpue oft sat of this permit.
,9 AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
MID o Appli a Date f7 IXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
ZARDOUS MATERIALS DI SCWSURE ,
Wiiltheapph sat orfaure buildingocaupantatme or handle hazardous HEATING UNIT(101D0,000 BT[n Date Recei t#
material as dented by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Cade Section 25532(x)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: a,J
F1 Yea No
Will the applicant orlm building occupant use equipment or devices VENTILATION FAN(SINGLE REBID) IS�A ( y)p TE
which emit ham rdous air contaminants as defined by the Bay Area Air IF Li-
oality Management Distr4t7 BOMER-COMP DEEP OR 100,000 BTU)
Yee [' No
Ihavertheh 9,Safes materials tions 2mcnh5533 an 255346.95 of BOILER-COMP(OVER 100,000 BTU)
the Californianla};earth 9,Safety Code,5ectlomu 75505,25533 and 25534.I Fj
understand that if uil
thebdingdoxe not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT
responsibility to notify the occupant of the requirements which most be met �/VrC•..
prior to issuance of a Certificate of Occupancy. GkII Ur
Owner or authorized agent Date ISSUED V
TOTAL: ✓
OFFICE COPY
a