23581 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro ad Identification PERMHNO.
BuildingAddress;
23581
o30,3
_arse:
.5.3 vay Lrv.ar.NT
CITY OF CUPERTINO-BUILDING DIVISION
° ora N. j so APPLICATION /PERMIT l
5 BUfLDING-ELECnUCAL PLUMBING MECH LAICAL CATEGORY CONTROL M
ted gamer: Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addren: PERMITISSUANCE ❑ ❑
LICENBED CONTRACTOR'S DECLARATIONVS
I be
rebydfbm that l am kesued carder provLdons cf Chapter9(mmmen APPLIANCESRFSIDENTIAL JOB DESCRIPTION
ingwithSecli.n7000)ofDiWgm3oftheBualneseandPmfe =,Code,and my
licanse is In(u coca end died. PANELS
,ate
license Clan Lletl 11Nl�
Dale Contractor UP 7000
ARCHITECTS DECLARATION AMPS
^l O I understand my plane shag be used n public reroM�. OVER 1000 AMPS SQ.FT.FLOOR AREA ^ $/SO.FT.
{.16al.ly�j Licensed ProtenWrul SIGNS ELECTRICAL D g`'
1-n 6 OWNER-BUILDER DECLARATION SPEOTALCIRCUIT/MIST 9r,��1
0 I here affirm that l am exam from the Contractor'.License Law for the YB,••(l
g ppp�ppQ felluwing....(Seal.7031.5,Businm and Profeubns Code:Any city or T
p F' cauntywhlchrequr apemdtwmru cu alter,Impmve,demo h,ormpair TW"P.METERORPOLE WST. 1
finSSO a anystmetume prtortaib WuamgaWrequireatheappHmntforsurh pemdtto
V file a signed statement that he te licensed pursuant to the provisions of the POWER DEVICES s '
3Ot� Cunlradoes Lkense Law(Chapter9(commencingwllh Section 7D00)of Divi- SWIMMING POOL ELECTRIC
N S amn3 ofthe Builnmand ProfeseiomCade)orthat bete exempt therefromand VALUATION Q 6,
o the bleb for the alleged exemption. Any ,violation of Section 703IS by any OUTLEISSN711CHESFf)(TURES N^^a 0 Q .
applicant for a permit subjects the applicant to a civil penalty of not morethan
time buns ed owner of
NEW RESIDENTIAL ELECTR SQ.FT. ES TYPE CONSTRUCTION
�n ❑I,as owmr o!the property,or my employees with wages a[bete sole
compermation,willdo the work and the structure is not Wended or offered for
O sale(Sec.70K Bualneu sad Professions Code:The Contractor.Lt..Law
c$'$ does not apply to an owner of properly who builds or Improves therm,and OCC.GROUP RES.UNITS
whodma.uchwarkhlmeeBorthrwgh Msownemploym,provided that such
Wprovements arc not Intended proffered tarsale.If,however,Ihebulldingor TOTAL:
improvementtemldwithin°myearofcomp101b theowner-bullderwlllhave
ft.k.rden of proving that he did not build or improve for purpose of sale.). QTy, BING PERMIT FEE FLOOD70NE 'APN
LJ L as owner of the property,am exclusively onsumcurg with Ikensedi'QtM1.1.15WANCE
o
camosc s to construct the project(Sec 7016,Business and Profeselom Code:
7fie Contra
does Licemue Law dm cad apply to an owner of property who ALTER-DRAIN VFM'-
bullda or Improves thermry and who contracts for such pem 6ojwith a WATER(EN
ry➢t[�dorW licensed pursuant to the Contractor'.License Law. FEE SUMMARY
,am exempt under See. B A P C for thin reason BACK FLAW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Dale RFAEp.(0
WORKMAN COMPENSATION DECLARATION
FIXTURES.PER TRAP ' SCHOOL TAX Y N
❑I hereby affirm that I have•cartiflate of consent to opytheure,(Sa RECEIPT Y
38m,Labcertificate ofWorken'C°mpematlonimurance ma cartifkd copythereo((.Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y_ N_
3800,Lab C.I RECEIPT 4
Paltry tl GAS PA.SYSTEM-OVER 6(EA)
Com any BUILDING DIV]SION FEES
,CertlOeH copy is hereby FuMahed. CREASE•/INDUSIRL WASTE INTERCEPTOR PLANCHEGIC FEE
❑Cerifled ropy is Ned with the city Wpection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASETRAP PAID '
COMPENSATION INSURANCE SEN'FR-SANITARY-STORM EA 100FT Date Revel t#
(Thlssectlon need not be completed lithe permit is forom hundred dollars
($100)orleea.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y - N
I cartlfy that In the performance of the weak for which We permit b issued,
=I slug not emp any person N any canner a to become wbje t 10 the WATER SYSIEM/TREATING '
k1..0 11 nIavn la, a PAID
Z Z APPilcant NEWRESIDENTSALPLMB. SQ.FT. Dale Recei f#
NOTICE C If,aft. maWngt b ert Inle Exemption,you
aheuld become Pct totfie Worken'Compensatlonp telom ofthe Labor TOTAL:
I N Code,yeu r. fMhwith comply with auchprovteiom rthlspertNlshallbe BUILDING a D
W j deemd revoked.
[LCONSTRUCTION LENDING AGENCY SEISMIC FEE
I hembyaffirmthat there is a comtructlon lending agency for the perform TOTAL: ELECTRIC FEE
Z anceofthe workforwhkhthis permit Is Issued(Ssc.3097,Clv.C.)
U O ender'.Name PLUMBING FEE U
LL I— Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Indlfythatlluvereedthteappgcationaralpatethattheaboveinfor tam
bmreac.I agree to comply with all etyand county ordinanm and pale laws PERMIT ISSUANCE FEES PAID:
6
r relating tobullding cernmRlon,and hereby authoatae represenlativn ofthis
F N city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MFCH.
Z (We)agree to sav4 Indemadly an d knp harnde s the City of Cu part[. Date Recei t#
V agaWtgabWtles,Fmdgmenb,copeend xpenmwhichrraym.rywayamue AIR HANDLING UNIT(TO IO,ODO CFM) SUBTOTAL: VL
Et said City in con nceoft gpnling thlapecout.
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX I
S rep Appg nt/Contmdm Date EXHAUST HOOD tW/DUCT CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS SCLOSURE
Z11 the applicant or future building ottvp tatore or handle haaardouc HEATING UNIT(TO 100,000 BTU) Date Revel t#
cruertalaa defined by the Cupertino Munkl Code,Chapter 9.11,and the -
HealthandSafetyCode Section 2S531(a)7 HEATING UNIT(OVER 100,[00 BTU) TOTAL:
❑Yes LIN°
Will the applicant or Future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE ATE
which cent haeardous ab contaminant,as defined by the Bay Area Air P A
Qua thy Ma wgement District? BOILER-COMP OHP OR 100,000 BTU)
Yn ❑❑No
have read the hazmdous materials requirements underChapter6.95uf BOLER-COMP(OVER 100,000 BTU) 27 ]992
The California Health A Safety Code,Sections 255D5,25533 and 25534.1 APR u ociersta nd that if the building dm not currently have a tenant,that it is my NEWRERDENTIALMECH. SQ.FT
responsibility to notify the p.m I The requirements which must be met
prior to issuance of a Certificate of Occuparacy. 1'y'Uf III
Ownermituthartaed agent Data ISSUED BY:�•
TOTAL
OFFICE COPY