23138 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro cn Identification ///'''��� PERMIT NO.
Bu lld ing Addrrens: 23138
Z
WN CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT BUILDING-ELECTMCAL PLUMBINGMECHAMCAL CATEGORY CONTROL#
Llc.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add.. 9.7 PERMITISSUANCE I ^ Ike! 1:1 1:1LICENSED CONTRACTOR'S DECLARATION I(�
Iherebyaffirm
thatl cen3deur provisions s of Chapter 9(cxmrew APPLIANCES-RESIDENTIAL JESCRIPTION
of ohd
ingwithSection B ,inenandPrefessionsCode,anciny
License le In full j/ PANELS
Llmnx Clan . EcrsW6.
Dates ontmdor UP TO 2DO AH�S
ARCHITbe us CLARATION OVER
I OAM
,#+00 Zp (understand my plans eha0 be and as public records. OVERIOW AMPS SQ.FT.FLOOR AREA S/SQ.FT.
Ely Licensed Professional NS ELECTRICAL ,
OWNER-BUILDER DECLARATION
�n] SPECIAL CIRCUIT/MISC
7,s' Iherebya(flrm that lam ezempt(romthe Contractor's Llann Law for the
L
llowing reason.(Section 7091.5,Bu,lnen and Pmfesslons Code:Any tltyor
Ftywhich requires,permit toconstmct,alter,Improve,demolbh,orrepalr TiMP.MEILR OR POLE INSf.
ystm=mpdortoltsbnuance,alsomquirestheappllantforsuchpem tm P]4VF.R DEVICES
e a signed statement that he Is licensed pursuant to the provisions of the ontrattore License law(Chapter9(commencing with Beal°n 7000)of Dlvl- Sy IMMING POOL ELECTRIC VALUATION
n3 of the Business and ProfssionsCode)orthat he b exempt therefromande basis for the alleged exemption. Any violation of Section 70115 by any OUILETS-SWITCHESH%TURES /'y-�pliantfora permit subjects the applicant Wa civil penalty of not morethan C..�.�/
n hundred delta.($500). NEW RESIDENTIAL ELECTR
I,as owner of the property,or my employees with wages as their sok SQ'FT' RIES TYPE CONSTRUCTION
mpenutlon,wBldothe work and the structure is not Intended or offend for
O� sale(Sec.7044,Buslneu and Pmfeaiom Code:The Contractor's License Geo
�$ does notapply torn owner of property who builds orlmpr°ves thereon,and DEC.GROUP RFS.UNITS
does such work himself or through his own employees,provided that such
Improvements are not Intended oroffered for ask.If,howevegthe buiklingor
improvementbwldwithinoneyearofcompletioktheowner-bullderwlilluve -
the burdenofproving that hedid net Wild orlmprovefor purposeofsale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
0 I,as owner of the property,am exclusively contracting with licensed pQ(MCf ISSUANCEcontralto.to construct the prejactec
(S .7044,Business and Professions Code:
The Contractor's License Taw doe,not apply to an owner of property who
builds or Improves thereon,and who contracts for such p ojccta with a ALTER-DRAIN&VENT-WATER BIA)
c,altact°r(s)Bmnnd pursuant to the Contractor's License Law. FEE SUMMARY
LJ I am exempt under Sec B k P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR,ROOF,AREA,CONI). SANITARY Y N
Owner Date RECEI T N
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of convent to calf-Insure,ora FIX.Il11iES PER TRAP SCI{OOL TA% Y NRECEIPT Y
3800,Isis S F.A.
cedifiratea(Workem'Compematlonlmunnmoraartifiedmpythereof(Sec. GASYSTEM-1 INC.40IJILE-f5 PARKFEE Y N
Policy p RECEIPT a
Com an r' CAS RA,SYSITM-OVER 4(EA) BUILDING DIVISION FEES
CertiO pyta ff,59 FAF.Iahad. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
led copy Is filed with the city inspection dlvlslon.
CERTIFICATE OF OfEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATIONINSURANCE SEWER-SANITARY-STORM EA.200F17. Date Recei t#
(Thlavectton need seat be completed the permit b for one hundred Bolla.
p10(lorlea.) WATER HEATER w/VENT/ELECTR ENERGY FEE Y N
I amlythat In the performance of the work for which this permit b bored,
I shall not em to y person In any manner so n to become subject to the WATER SYSTEM/TREATING Workers' nsation laws o(Callfornla. Date PAID
Z Z Appllcan NEW RESIDENTIAL PLMB. SQ.FT. Date -Recel t#
TI
O NOCLCTO APPLICANT:ILafter making this Certificate of Exemption,you
should become subjed to the Worksrs'Compdmtlon provblons of the Labor TOTAL:
N
Code,you=at forthwith comply with such provisions orthb pe.rdt shall be BUILDING
LU C deemed revoked.
aCONSTRUCTION LENDING AGENCY SEISMIC FEE
Iherebyaf(Irmthmt isadonstruclon lending agency for the perform ELECTRIC FEE W—
Z anofth,work this permit ta bxued(Sm.3097,Civ.C.) TOTAL:
u2 LaZrb Na PLUMBING FEE
LL 1- Lendee.AQ ve QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Imrtlfythatl have read this appliationand gate thm
attheabove lnforatlw
IL 'correct.I agree to comply with all cityand countyordlnancosand nate lave PERMITISSUANCE FEES PAID:
>- relating to building censtruction,and hereby authorize representatives of this
N -
�— Z sty to enter upon the above-mentioned property for Inspection pu rpoaes. ALTERORADDTOMECH.
_ (we)a e to rave,indemnify an d keep harmless the City of Cupertino Date Receipt#
against Titles menteMatsand expert hlchmaylnanywayacaue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL'
aRat id C' o e of Fits permit
- /" aiT HANI)UNc uNrr(ovH{Ia,000cEM) CONSTRUCTION TAX
SI arum pB /Contractor Date EiHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant store or handle hazardous HEATING UNIT(TO 100.OM BTU) Date RCCCI t
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the -
Ilealthand Safety Cod ion 25532(a)T HEATING UNIT(OVER 100,000 BTU) TOTA
qYes No
WiEtheappllant o re building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Qua Ilty MawgementrNo BOILER-COMP pIIPDR 100,00D BTU) PAID
4Yes No
hreadtheta et materials requirements 5533underaChaplet. 1 of BOILER-COMP(OVER IOD,000 BTU)
the Californta Health kSa(ety Coxo not ions T5505,2533and7.553Ilt DEC 31 1999
LLCdtha 'f a bulldlog dem nota ntly have atenanl,that It Ls my NEW RESIDENTIAL MGCH. SQ.IT. ,
m slit the occupant oft Iremenls which must be met
C Lss a f ry. l Ua�tyJj IIS
Ownerer authorl' agent ate ISSUED-By.
TOTAL:
OFFICE COPY