23977 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Pm'ea Identiflolion PER.VITNO.
Build Leg Add 4s:,s wtirf �Yf 23977
Znn ((/,( one A - A A
a .
7 .6/o"i t e / CITY OF CUPERTINO-BUILDING DIVISION
ntn •" ° 1t ��7�S I€jLi=. APPLICATION I PERMIT II b
• r a[ BUILDINGMECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROLN
Archlted/Engineer. Llc.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
PLUMB M�H
Address: PERMITISSUANCE ❑ 1:1 El
CONTRACTOR'S DECLARATION
I hereby
Seaton ro 70000tl Divisised on
ofthe erprwlslons of Chapter 9nonsC de,and c APPLIANCESRESIDENITAL ]OB
Ingwith5ection7000)o(DlWslon3ofthe 0uslnessan (essionaCode,and my
Ilconse is in fu p dfect. PANELS C/
Date Contactor
AR HI CIPS DEC RATION 101-1000 AMPS
PCOC I land my pl u bloc s OVERIWO A.MIPS SQ.1-7.FLOOR AREA S/�.FT.
Z U ice sed Professlo SIGNS ELECTRICAL
<�Z, LED IN
OWNER-BUILDER DECLARATION SPFGIpLCRCUIT/MLSC
owing afftrmthat lamexemptlromthe Cont lassoo sCodee Lawforehe
oo
following reason.ices a p m t.5,Business and Propews, Code:h, d or L—L T R
in y ty TEMP.METER OR POLE INST. CY.-+
r4 countywhicM1requlreeapermite,roorequielter, apmvgdennlbh,orrepair
�§ anyatmdure priartostatement
its hatsa a is also sed purtheapp the ro suchpermitof it a POWER DEVICES
yrs.' floe a signed ice.La that het licensed pursuant it the le.70om of the
30
Contractor.3oftheLicenseTaw(Chapter9Cm e).,thatmerang withSectionhemfof and SWIMMING POOL ELECTRIC DATE
soon3o(the BusNeasand Pro(emlow Code)orehat he Vexempttherefromand TION
the bash for the alleged exemption. Any ululation of Section 70315 by any
oapplicant fora permit subjects the applicant to a dull penalty d not more than OUTLETSSWITCHESFIXi'URES �� O
^y five hundred dollars(g50�. NEW RFSIDEJTIAL ELECTRSTORIES.Y
p
]!2
! ❑I,as owner of the property,or my employees with wages as their sole S'FT, TYPE CONSTRUCTION
< compensation,will do the work and thestrudure b not Intended or offered for '
5 D sale(Sec.7044 Business and Prefeasiow Code:The Contractors Llcone,Law
does not apply to an owner of property who builds or improves thereon,and
whodoessuchwork himself or(hreugh hisownereployees,provided that such OCC.CROUP RFS.I1NR5
improvements are not Intended oroffered fmsaoe.If.however,thebulldinger TOTAL:
i provement Lssold Mthinoneyes,ofmmpldl. ,theowner-builderwillhave
tni,4meden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEEFlppDz,)NE ,ApN
Lj L as owner of the property,am exclusively contracting with Ilmnsed PERMIT ISSUANCE
rontradms to corstrud the pmiect(Sec.701,Businex and Profealom Code:
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN -WATER ffN
Wilds or Improves thereon,and who contracts for such pWjecta with a
on,IIt..,r,actor(s)Rconeed pursuant to the Contracture Lia, s Law. BACK FLOW PROTECT.DEVICE
FEE SUMMARY
LJ I am exempt under Sec. B&P C for this reason
dQTSIDI F1 E,
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
• Date RECEIPT N
MI WORKMAN COMPENSATION DECLARATION
hereby affirm that 1 have i comRate of consent to copy
ora F'IXN7(ES PER TRAP SCI100L TAX Y_ N
MY),ate Of Worken'Compersalion INYnnm m i certified copy thereo!(Sec. RECEIPT N
MY),Lab C.) /19 CAS EA.SYSrEM-i INC.40UTLEIS PARK FEE Y_ N
I'a1ry,N RECEIPT M
Com any If1 GAS EA.SYSTEM-0VER4(EA) BUILDING DIVISION FEf:S
�CeAlOed copy E here shed. —
�QettR2d
copy is filed with the city inspection division. - GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE
(Dissection need na becwnpleled lithe permit Laforonehundred dollars SEWER-SANITARY-STORM EA.200FI'. Date Recei t#
(51 I0)orfy that
WATER HEATER W/VFNT/ELFCTR ENERGYFEE Y N
I ll nor that o the performance of tmanner so a to l this posit is WuN, —
I Ork nor employ any person In any manner at as to become wbject to the
WOrken'COmpenullon laws of California.Date WATER SYSTEM/TREATING PAID
O Z Applicant
Z O NOTICETOMPLICANT:If,akermakingIhs Certllateof Exemption,you NEW RESIDENTIAL PLMB. SQFT. Date Revel t#
should become subject to the Workers'Compern tion provisions of the Labor TOTAL:
LUW Cade,you must(Orthwith comply with such proWalom orth6 permit shall be
> deemed revoked. BUILDINC,ITE
CL p CONSTRUCTION LENDING AGENCY SEISMIC FEE
= Z IFerebyafRrm that there Is a mrutrudion lending agency for the perforne TOTAL: ELECTRIC FEE
once of the work far which this permit Is issued(Sec.3097,Civ.C.)
U O Lerner'.Name !FEES
BING!FEEly F ndersAddress QTY. MECHANICAL PERMIT FEEANIEE
O W Icortilythat I have madthuapp0ationand statethatthcabove information
C is correct.I agree to comply with all city and countyordinanees and state laws PERMIT ISSUANCE PAID.F- N relating to building construction,and hembyauthortaurepresentativesOfthisF citytoenteru nthe abovementioned property for Inspection purposes. ALTER ORADDTO MECH.(We)agre to save,indemnify and keep harmless the City of Cupertino ate Receipt#
againstfiabtiea,judgene b,cods and i.paueswMchmayi.anywayUNIT a.c AIRHANDLING USUBTOTAL:
against City Ucon a the ant[ dthlspermit.
6 AIRHANDL1NGUNTT(OVFBI0,BslCr•M) CONSTRUCTION TAX
Sig of Appli nt/Contractor Date allAusT HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle ha,adous HEATING UNIT(TO 100,0008
material as defined by the Cuperti MunlapalCode,Chapter 9.12,and the Date Recel t#
Halthand SafetyCode Se 2(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL.
❑Yes
Will the applicant or future building occupant useequipment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emitva
hardous alt antandnants as defined by the Bay Area Air
Quality Management District? BOILER-COMP 0HPOR 100,000 BTU)
Yes he �o
have read ealtha ouN Safety
Cud i ls Sabo requirements andChapter 2554.1 of BOILER-COMP(OVER 100,ON BTU) Pq B0
the Goland is Health&Safety Code,Scctiore 25505,have
a t and 25534.I ,
undersbndt tiltM1c building does nor currently Faveatenanp that it NEW RESIDENTIAL MECH. SQ,FT' /F�
r¢poaibll' to naify theocmpant dthe requiementswhich must be and V
prior to ce ofa I!i 8c to pan 9
. u'
Owner or authorled agent D e r /
TOTAL: ISSUED BIV
OFFICE COPY