23766 (2) PPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Addreaull Protect dend(kal°n 8 PF1RWT NO.23766
ria^. sous: r .
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Onenttar's Name: � 254 'One
CITY OF CUPERTIN0.BUILDING DIVISION
(_TON WAW6 "°` APPLICATION /PERMIT
Architett/En er. LIc Nee - Bl1ILDIN-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL X
N vN�1G
/ � p QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. Q3-1 S� Lv�• .
PFRtATI55UANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Iherebyafflrmlhatlamlicensedunderp—WonnofChapter9(mmma,c APPLIANCESRESDENTIAL
Ing with Sectbn7001Bot Dlvleton3oftha Bualnerand PmfesYonaCOde,and m IOD DESCRIPTION
license lalnfuB force and pANrgLq ���76 `�
Llanse Cbr Lk.N `v 1(`
Date CDMactor
ARCHITECTS DECLARATION 201-1830 AMPS
NO p I uMentand my Ebro elul4 used r public records. OVER 1000 AMPS
❑ =AR'!AIISQXLi Osed Proferlonal SIGNS ELECTRICAL
yOWNER-BUILDER DECLARATION
Ihereby affirOthat l am exempt from the Contractor's License Law im1he SPECIALCIRCUIT/MLSC
following rerun.(Section 70315,Business and Prefess)ORs Code:Any city or
cauntywhlchrequkexaperm)ttommt Mg ter,lmmve,demoBsh,ormpar TEMP'METER OR IDLE INST.
anystrooureprtortoitsbsuance,ahomulastheappliamforouchpermato10P(14a slgnad statement that he b Ilansed pursuant to the proWlor of the POWER DEVICES
Contractors Lkaue Law(Chapter9(commencing with Section 7000)°(DIW-
sbn 3Ofthe Busher and PMerbmCode)or that he laexempt therefromand �tMMING POOLELECTRIC the hash(or the alleged exemption. Any violation O(Section 7031.5 by any
p appllantfor&permitmbjettstheapplicant tuactvE penahyoina Qmthan OUTLETSSWITCHESEXTURES
,q Rvw�undrad dollars(§500). -
GGG111 Sn �Ij.�,ae courser o(the property,or my employers with wages r their sole al RESIDENTIAL ELECTR_SQpr. STORIES TYPE CONSTRUCTION
�a penrtlon,wllldothe work,and theattucturebrrot Intended or offered for
O r e(Sec.7064,Business and Pr0(erlatu Code:The Contrattofs Llcere Law
�$ docs not apply tom ownerofproperty who Wilde or lmprovesthereoR and
whodoasuchworkhimxl(orlhrough hlaownemployres,provkled that such OCC.GROUP R LMTS
Improvement are not Intended oro(fered fasale.[(,hmvever,tha bulMing or TOTAL:
improvement b sold within Oneycaro(completloR the owner-bullderwlll love
t ben of provingthat he dM not build orimprove for purpwe ohale.).
QTY. PLUMBING PERMIT FEE
u[ae owner of the property,am exdualvely mntrading with Ikeneed E1.00D TONE APN
contractors to corWctihe project(See 7014,Business and Pro(mlor Code: PERMIT ISSUANCE
The ContnttoYe Lkaue Law dace not apply to an owner of property who
bullets or Improves thereon,and who mntratts for such p(Okrn with a ALTER-DRAIN VENT-WATER(EA)
C1Rl[actm a censerupt pursuant to the Conlncta'sLk&rue,PLaw. FEE SUMMARY
LLII I am exempt under Sec B&P C for thio rerun BACK FLOW PROTECT.DEVICE
Owner OUTSIDE FEIN
ate DRA)NS FLOOR ROOF,AREA,COND. SANITARY Y N
WORKMAN COMPENSATION DECLARATION RECEIPT N
❑I hereby affirm that I have a arti(late of consent to sell-insoQ
re,or a FIURES PER TRAP 5CI100L TAX -Y_ N_
• artNate ofWorkers'Compensation Insurance or a artiflcd copy theme((Sec. RECEPIX
3800,Lab C.) GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y_ N_
CoX _ — RECEEPT X
gzCCAS EA,SYSTEM VER4(FA) BUILDING DIVISION FEES
fied copy b hereby fumished.
❑Cert:fied copy Is filed with the city Inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE
(ThiasectlonneM nut becompleted lfthepemdt hfaonehundred dollars SEWER-SANITARY-STORM EA,2001T. Date Rece1 W
01100) lil th ENERGY FEE Y N
I snot that employ
an person In
theworkmanner so as to become
penctitis booed, WATER HEATER W/VENT/EI.CCTR _
Workers'
not employ any pen"In any manner at r to bosoms object to the
O Walicant Compensation lawn of Glifomb.Date WATER SYSTEM/TREATING PAID
Applicant
20 N'OTICETO APPLICANT:R,.mr makdngthb C.njfo &F emption,you NEWREIDFNTIALPLMB._SETT. Daft Recef t#
W should become subject to the WOrkars'Comperaton provbior ofthe Labor
Code,you=at forthwith comply with such Provisions orthls permit shall be TOTAL:
W > deemed revoked. UILDTNG .
IL C CONSTRUCTION LENDING AGENCY SEISMIC FEE
I Z herebyaf(Irtnthat then h a construction lending agency for the perfomn-anceofthewcrk(orwhkhthhp (See
emdtbeuuM3097,Civ.C.) ELECTRICFEE
TOTAL:
U O Lender'sName PLUMBING FEE
U. H 'Lendcr'a Address QTY. MECHANICAL PERMIT FEE
O W I cerblythal i haveread thlaappllatbnand a tatethattheaboveln(omutlon MECHANICAL FEE
1 borne.l agreeto comply with all city and county ordinances and Yate laws PERMIT ISSUANCE FEES PAID.
>. N relating to building construction,and hereby authoAze representatives ofthis
F Z city to enter upon the abovcmentiored property for Inspection purposes. ALTER OR ADDTO MECH.
(We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
agairt liabilities,Judgments,costs and expenses which may In any way accrue AIR HANDLING UNIT(PO 10,0DO CFM)
agai Inconsequence Ofthegrantingofthb permit SUBTOTAL:
AIRHANDLINGUNTT(OVER10,W0CFM) CONSTRUCTION TAX
Sigv ureot AppB L.,meor Date EXHADST HOOD(W/DUCT) CONSTRUCTION;R�eip
AID:
HAZARDOUS MATERIALS DISCLOSURE
Wlllthe applicant orfumm building Occupant stomor handle haaardous HEATING UNIT(TO 100,0008
material as defined by the Cupertino,Municipal Code,Chapter 9.1 2,and the Date t#HealthaM Safety CMe`Seytlon 2$$32(a)7 HEATING UNIT(OVER 100,"REM AL: t
Fl Yea �LVVJJND
Rlthe applicant Orfuture be tiding occupant use equipment a devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emtt harrdousair co taminacm as defined by the Bay Area Air
Quality Management Dial 7 BOILER-CAMP OEM OR 100,D00 BTU)
Imo,Yn IrTyl No PAID p p�
have read the baso °usma[erlab requirements under Chapter 6.95 of BOILER-COMP(OVER 1(10000 BTU) y� A I D
• the California Health&Safety Code,Sections 25505,25533 and 2SS36.1
understand that if the building does not mmmly have a tenant,that it b my NEW RESIDENTIAL MECH. SQJ T7
rr9 po,nlbility to not ify the Occupant of the requirements which mu at be met JUN v1.7c7G
prior to Issuance of a Certificate of0ccupa ncy. 2 'I[JQQ
t
Owneaaulhalud agent Data CITY '
TOTAL: ISSIRiD BY:
OFFICE COPY
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