23091 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —'USE BALL POINT PEN ONLY
Building Project Identification - PELWT NO.
Butldir Address: 23091
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cane44-1xv,A4r a rvarre: I Phone
�JOS�v'- / !I K CITY OF CUPERTINO-BUILDING DIVISION ^ 1 A A
c°rtra iaNa Lie.No APPLICATION I PERMIT L/l
• Architect/Engineer. Ie No: BUILDINGELECTWCA[.PLUMBING-MECHANICAL CATEGORY CONTROL N
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address, 51.121L. ELECI PLUMS M�f
I'ERhIIrISSUANCE 1:1 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION X.
I hereby affirm that l am licensed under provisions of Chapter9(commenc APPUANCBSRESIDENFEALlngwitJOB DESCRIPTION
limm.h I bull to 0)ofd off on3ofthe Businessand Pm(esslonaCode,and my
license is L full force and kcN n .) PANELS
License CVs Lk.N ! 57
Date ContactorUP TO 2DO ANTS
ARCHITECT'S DECLARATION 201-HOOAMPS
aO ZpC I understand my pian shall be used as public records. OVER IOOO AMPS SQ.Fr.FLOOR AREA $/SQ.F(.
k z U Limned Professional SIGNSELECTRICAL
<<�<N OWNER-BUILDER DECLARATION SPFGIALCIRCUIT/M15C
7 Z Ihereby affirmthat I am exempt them the Contractor'sLicense lawforthe
p following reason.(Section 7BH5,Business and Pholmlon.Code:My city or
O Z I-µ9 TEMP.METER ORPOLE INST.
rr,� countywhichmqulrcsa isauance,tomntrouiresthe, aprovgdemsuch,or rcpilr
�y ,a any a signuretatemeitshat hofs abensed rersuant pBaeHoemchperrnite POWER DEVICES
C c.U to
file a signed statement that het Boned pursuant to the provision of the
O w Contractor's .ic a law(Chapter 9 Cm e)ortlng with Section he m)of Divl-
�io30 the basis fortealleed Professions Any violation V emm therefromand SWIMMING POOL ELECTRIC VALID"
<'N the bash for the alleged exemption. Any violation of Section does
m by any
a lhundred ars $ub' thea B tt°ativll 1 o(not more than OUTLETSSWITCIi[SHXTIIRES
PP a )acts PP can penalty
flue 1,as owner of the pr. NEW RESIDENTIAL ELECTR
,Z ❑I,as owner of the property,or my employes with wage as thele sole �'� STOW TYPE CONSTRUCTTON
cm(Sec.lion,willquid...and rk.andthe etmds: he Contended or offeredLaw
O vie(Sec.9041,Business and Profession Code:The Contractofs Llcene Law
�SR does not apply to an owner of property who Wilds or improves the er,and OCGGROUP RF UNUS
who does such work himself or through his own employees,provided that such
improvementsarenot Intendedorofferedforsafe.If however,thebuildingor TOTAL:
improvement Issoldwithinoneyearofcomp]Mib theownenWBderwillhave
te edenofpmving that he did not W x
ildorimproveforpurpoofsakLOODz NE.). QTy. PLUMBINGPERMIT FEE RANN
Lj L as owner of the pmperty,am exclusively=trading with licensed PERMIT ISSUANCE
contractors to construct the project(See.7044,Business and Professions Code:
The Contootor's License Law does not apply to an owner of property who ALTAR-DRAIN VENT-WA
Wilds or Improvesct
thereon, and who comms for such pkojetts with a
on, tt(+ctor(s)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT DEVICE FEE SUMMARY
iJ I am exempt under Sec. B k P C for this moon
OUTSIDE FEES-
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Date R NG X
WORKMAN COMPENSATION DECLARATION F1X'NRES ITER TRAP —50100LTAX Y N
❑I hereby orkem that I have o artilmuR a of consent to seythI ure,ora RECEIPT N
c W,L.bC.Workera'CompewHonlnurance oracertifkd copy themrof(Sec. GAS EA SYSTEM
.1 Lab C.) lINC.40I1ILE15 PARK FEE Y N
Poli M —
Cor,any GAS EA.SYSTEM-OVER 4(EA) RECEIPT p
�Cerolled copy is hereby furnished. BUILDING DIVISION FEES
CjCrAlfied copy isfiled with the city inspection division.' GREASE/INDUSIA,WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS- CREASE TRAP PAID
COMPENSATION INSURANCE
(Thissectlon need not becompleted lfthepermit leforom hundred dollars SEWER-SANITARY-STORM EA."FT. Date Rempl#
(5100)orfy,th) WATER HEATER W/VFNT/ELECTR ENERGYFEE Y N
[certify that Nthe performance aofthework fors to become
permit is issued, —
1 shall not employ any person In any manner at n to become wbject to the
O WaCompensation Laws of CalBomla.Data WATER SYSTEM/TREATING PAID
Z Applicant
Z O NOTICETOAPPLICANr:I,akar making thio Certlflate of Exem)xlon,you ' NEW RE9DENTIAL PLMB.__JQFT. Date Remi t#
N
should become sub ec"o the W°rkers'Compareatfon provislon of the Labor TOTAL:
a. Code,you must forthwith comply with such provision mthis permit As[]W
W > dermad revoked. BUILDING 'E
CL p CONSTRUCTION LENDING AGENCY SEISMIC FEE
= Z I hereby affirm that there is a construction lending agency for the perform ELECTRIC FEE
O ante otthework for which this permit vw>,ed(Sec,3097,Civ.C3 TOTAL:
L) Lenders N.me PLUMBING FEE
U. F larder's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertlfythat l havemad this application and statethatthe above lnformatlon
4 bcorrect.I agree to complywith all city and rounly ordinances and state laws PERMIT ISSUANCE FEES PAI D:
} N relating to building contnctiogand herebyauthorize representatives ofthla
Z city to enter upon the above-mentloned property for Wpection purposes. ALTER OR ADD TO MECH.
� — (we)agree to save,Indemnify an d keep hareNm the City of Cu pert iso Date Receipt#
agaWtlobllitlee,judgments,consand expenses 7 hmaylnanywayamrus AIR HANDLING UNIT 10,000 CFM) SUBTOTAL:
agalnt Id City In mnsequenceo canting of ala perp -
(K/ l AIR HANDLING UNIT(OVER 10,000 CI I) CONSTRUCTION TAX
Sig hereof AppB ntxrmtractor Date EXHAUST 1100D(W/DLTC T) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WIIIthe appBa or or future building—part store or handle haeardous HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date Recei t#
Health and Safety Cede Semon 25532(.)7 HEATING UNIT(OVER 100,000 BTU) TO
❑ Yes NN. TAL•
Will the applicant or future Wilding occupant use equipment or devices VENTILATION PAN(SINGLE RFSID) ISSUANCE DATE
titch emit ham rdous air contaminants as defined by the Bay Area Air
. it�Managcercntl utctr. No BORER-COMP PED'OR 100,0M BTU) T)5 A r Xaa
have mad the haus ouamatcrials requirements a nder Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) Y' M Y
the Cslifomh Health k Safety Code,Section 25505,5533 and 25534.1 DEC 11f1f1
understand that ifthe building don not currently have.tenant,that it is my NEW RESIDENTIAL MECH.
tre1 '.
responsibility to notify the occupant of the eequments which swat be net SQ}7 677
prior to Wuance of a Certificate of Oavpa ncy.
C17Y Ut CUPEn u� �
Owner or.uth.nmd agent Date
TOTAL: ISSUED BY:
OFFICE COPY