23236 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PELMITNO.
Building Address; �O t3L0�,� sW�' _ 23236
rune e a` pw�, APPLJCAllONSUHMIrFXr CITY OF CUPERTINO-BUILDING DIVISION A
actor' amY:^ ,�6 FF LIe•N. APPLICATION I PERMIT
BUILDING-ELECTRICALPLUMBINC-MECHANICAL CATEGORY CO
Archded/Engineer. Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERMI77SSUANCE BLDG ELELL PLUMB---MECFF_
❑ � ❑
LICENSED CONTRACTOR'S DECLARATION jr
I hehS affirm that fDiviscm3ofthe provisions PrfCha erg comm. A['IsI.IANCESRESIDENTIAL
Y under M ( JOB DESCRII'IION _
Inense l-eMallfia earideleion3o([he BuclneeeantlPro(eedonaCode,and my G<y�n C6F
limn.le ie full force and effect. PANELS v r f i. A}+a+�
DateLi ha
Date—Contractor Ir�lv9s'r���1� Ds
ARCHITECT'S DECLARATION 21VER I0AMPS SORA AREA
p�u�pqZ (understand my plain shag be used as public recede. OVER 1000 AMPS SQ.FT.FLOOR AREA 5/SQ.FT.
k o t Licensed Prof sidmal SiGNSELECTRICAL
rid u7 OWNER-BUILDER DECLARATION
+a
Z s,Y�1 I hereby afBrmthat I am exempt(romthe ContnRora Lken.him for the SP2ClALCIRCUIT/MISC
F
pp following reason.(SMion 70115,Business and Profen ons Code:Any city or
2, 0 TEMP.METER OR POLE INST.
El 9.
county requlrmapermktomretruct,alter, dennWh,or
g.a anystmmmpriortoi Lwame,aWrequimtheappUantfor3uchpermitto POWER DEVICES
1 file a signed statement that he is licensed pursuant to the provisions of the
3wG Contractor's License Law Chapter 9(commencing with Section 7000)of Divi- SWIMMING IDOL ELECTRIC
SOS sion3ofthe Busnma dPmfmiomCode)orthathebemmpttherefmmand VALUATION
the basis for the alleged exemplum. Any violation of Section 70115 by any OUTLET3SWITCHES-FIXTURES 4 p /�
applicant for a permit subjects the applicant to a civil penalty of vat more than QOV
five hundred dollars(,M. NEW RESIDENTIAL ELECTR
�n I,as owner of the property, e•RT'T STORIES TYPE CONSTRICTION'
p perry,or my employees with wagon r thele dole
Ocompensation,will doBinimi theas i work Tessio structure,durc V not Intended or offered for
ale(See apply Buslmaandf property
Code:The Contraarimpdols License law
3
does rotapply torn himself of(prough who bulmhrimprovethereoryand OCC.GROUP RES.UNITS
who
ovementswork hlm.Bedorwgh it own employees,provided that such
Improvemontsarenmintended oroofres pletion,thcorsale.If,however
men-bofiderwdingoe TOTAL:
Improvemem bwld within ons ycaro(completlorytheowner-builderwN have
tlK_kurden of proving that he did not build or Improve for purpose of side.). QTY; PLUMBING PERMIT FEE FLOODTANE APN
u L as or,of the property,am ezclmively.mead...with Ilmnaen, PERMITISSUANCE
contradicts to construct the pmjed(Sec.7099,Business and Profession Code: '
The Contradore License law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wild.or improves thereon, and who mntnds for such projects with a FEE SUMMARY
INadore)licensed pursuant to the Contndor's License Law. BACK FLOWPROTWT.DEVICE
am exempt under Sec B&P C for this reason
Owner Date DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RECEIPT Y
❑I hereby affirm that I have a certificate of consent to sell- FIXTURES PER TRAP SCHOOL TAX Y_ N
Ineure,or RECEPF Y
ceditlnte h(Workers Compematlonlmunnmoracedl(std copythereof(Sec. CAS EA.SYSTEM-1 LICA OUTLETS PARK FEE Y N_ '
PT 8
3800,lab G
RING DIV
Polity q CAS EA.SYSIT7A-0VER a(EA)
m y BUILDING DIVISION FEES
(fled mpybhercby, famished. CREASE/INDUSFRL WASTE INTERCEPTOR PLANCHECK FEE 8
Certified copy is feed with the city Inspection division. 1 13
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRA' PAID �f
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FI' Date Receipt#
(This section need net be completed 9the permit Is for one hundred dollars
(1100)orless.) WATER HEATQtWNENT/ELGCIR ENERGYFEE Y N
I cenifythat in the pedormanm mit of thewcrk forwhlch this peris lowed,
I aha 11 not employ any person in any manner.as to become subject to the WATER SYSTEM/TREATING
W.,iiaWCompematfm Linvoof Gllfcmds.Data
PAID
Z ZNOTlicant
ICE TO APPLICANT.If,after making this CertRkateot Exemption,you NEW RISID=- AL PLMB' SQ'I'f' Date RCR' t#
FO should became sub)m to the Workere Compenaation provisions of the Labor - T 9
tl9 Code,you must forthwith comply with such provisions,or this permit shallhe
W > deemed revoked,
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d Ihereby aflmithat there is a construction lending agency for the perform ELECTRIC FEB
M Z an ofthe work for which this permit b Issued(Sim.3097,Civ.C.) TOTAL
V O I�nder'.Name PLUMBING FEE
F lender's Address QTY. MECHANICAL PERMIT FEE
O W ImdlfythatlhavereacithbappBatbn.ndstatethattheabovelnfo.scion MECHANICALFEE
IL iscorrect.l agree to complywith all cityand county ordinances and nate laws PERMIT ISSUANCE FEES PAID:
>. reledng tobillddng construction,and hereby authorise representatives ofthis
F N city to enter upon the abov mentioned property for lnapedlon purposes. ALTER OR ADD TO MECH.
? Me)agree to ave,Indemnify an d keep harmless the City of Cu portion Date Reeei t#
V a galnathobiRties, dgments den n.e which my In anywayaccrae AR HANDLING UNIT CFO 10,ODO CFM) SUBTOTAL:
against sitting of this permit.
AR HANDLING UNIT(OVER I0,000CFM) CONSTRUCTION TAX
g reot AppR of/Contactor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE _
Will the applicant or future building occupant store or handle hazardous HEATINGUNITO100,O](HIM Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Codrea�Smlon 25532(x)? HEATING UNIT(OVER 100,000 BW TO
n Yes . uNo
Will the applicant orfdum building occupant use equipment or devices VFNITLATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP OHPOR 100,000 BTU)
Yea F-1
No
have mad the hazardous materials requirements under Chapter 6,95 of BORER-COMP(OVER 100,000 BTU) P A
the Califhmla Health&Safety Code,Sections 25505,2533 and 25539.1
understand that if the building does not currently have a tenant,that it is my NEW RISA DENTAL MEIN. SQ.FF.
responsibility to ,yY(yP[Y�`%)
ponsibility to net lfy the occupant of the mquimmenu which must be met FEB 2�j Igor
pdorto issuance ofa CertifiatecdOmpancy.
Owner or authorized agent Date TOTAL: ISSUE V " �IIVIJ
YIV&6a�
OFFICE COPY