23239 (2) APPLICANT TO FILLIN INFORMATION WITHIN RED LINES USE BALL''POINT PEN ONLY
Building Pre.0 IdentificationI PERMITNO.
BuRding Address: - -
/��5 J me5/nwn o/ �li e�f, 23239
nero ane:
�I.td,'M 1�enm1a�a& z53-280'l CITY OF CUPERTIN0.6UILDING DIVISION
C tr nor.Name: - Ll,.No:
APPLICATION'[ PERMIT. �3
�t MaS.4nnI �3fd=7519 BUILOINGELFCTRICALPLIIMBING-MFGHANICAL CATEGORY CONTROL
Architect/Engineer. / Llc.No:
QTY ELECTRICPERMIT" 'FEE BUILDING PERMIT INFO
Addrcuc e"5,le, e Sr7 9.Sas'
PIRhBTISSUANCE ❑ ❑ ❑
_ LIC ENS EDCONTR under SDCCns of ChON
- [hereby affirm that lam licensed under provisions o(Chapter9(mmmene APPLIANCESRFSTDENf1AL �� I
Ingwlih Sen1on70p0)o(Dlvlelon3 afthe Bu.lnemand PminslansCode,and m
tip
IimnselslnfvR ormandefect q PANELS
Llmnse ism We a 3035/ ) �.�
Date Cancra-o�-�'
ARCHITECTS DECLARATION XII-1000 AMPS
f 07. Iunderetand rrtyplans.haBWused upubllcrcmrds. OVERIOOOAMPS SQ.FT.FLOOR AREA $/SQ.Fr.
E Licensed Professional SIGNS ELECTRICAL A LED '
14
6 OWNER-BUILDER DECLARATION SPECIAL CgiCUIT/M1SC ��
7F, owing um.Chrtlam31.5,B from the Cantmnorl License LawAny fort he - PTEF
following g reason. ices a p 70!1.5,gastrum and Pro prove, Code:Any my or
O 9 TIMP.MEfEIt OR POLE[NST.
P county whichstore rugalreea pertNtloalsore uirestq he applicant
for such permit
S� .a any atsu nee statemenprierto ts hat he is lice sed pursuant pBcaet provisions
of e POWER DEVICES
Q63F pee a signed statement that he b licensed Damson[it the pro 7000) a( the
1., .Contmcios'.License Law mfuskmsCChapter 9 d ).rth.t hei Section exampatherefof Dfvi�
mand
��OS _elon3o(the Businem and Psvfemlou Codu)orthat hebexempt thercfromand SWIMMING POOL ELECTRIC 1 VALUATIO '
Q the basis for the alleged exemption. Ary ,violation of Stolon 70115 by any OUTLEISSWITCHESFIXTURES
applicant fora permit subject the applicant to a civil penalty of not more than I
five hundredsowner
hepr. NEW RESIDENTIAL ELECTR SQFr. STORIES 7YPECONSTRLCTION
I,as owner a(the property,or my employees in with ween as there woe
7Q compensation,will do Businethewokandthe,Code:The ot CIntendedo License
ed for
Law
❑ doie(Sec.apply
Easiness and Prooperty Codwho e:The or imp Roes Llmue law
$ dmsnet applylos.chwo,khmeowner olhrougho.onmemplymprovnthereon,and OCC.GROUP RES.UNITS
whoovements am not mseldedmotioned
tioedowne.If,ho epmvWedthatsuch
Improvements cid ithindneyearfcomplsion,th hmvevcbuilderwill g orhave
TOTAL: '
Improvement lucid within oneyearo(complNian,the owner-bugderwlll have ,
tliLhurdenofproving that he did not build crlmprove for Purpose olule.). QTY PLUMBING PERMIT FEE
H I,as owner of the roe BLOOD TONE APN
property,sty,am exclusively contracting with licensed PERMIT ISSUANCE
71.conCoostomrulrantLawdhe ct(Sec.appy to
end P fproou Coda: '
The Coor impro e.ther!ew don not apply c an owner d property who ALTER-DRAIN k VENT-WATER(EA)
Wilda tr Improve thereon,and who romracb (w such plvjeut with a FEE SUMMARY
coff] ar(sexemtorderPursuant
ce, McContractor's License Law. BACK FLOW PROTECT.DEVICE
LI t am exempt under Sec. B k P C for this reason
Owner - DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
Date RECEIPT#
WORKMAN COMPENSATION DECLARATION
' ❑I hereby affirm that I have•certificate of consent toopytneare,or . FD(TURES PER TRAP SCHOOL TAX Y N_
mniflcate of Workers Campenmtian Wurance ora certified mpythemo((Sec. RFL11 Y
3800,Let CJ r� GAS EA.SYSTEM-1 INC.6OUTLETS PARK FEE Y_ NN ,
Policy rAS P.A.SYSTEM-OVER I(EA) DINGRECEDF p
Com any -(}gygee ((e✓r� .r BUILDING DIVISION FEES
[CestlRed copy b herebyth the icy CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�y Ccrlitled copyb(Iled with the city inspection division. � ,
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA."Fr. Date Recel t#
(fhb secteon need na be completed If the perndl b fororm hundred dollars
(S1(10)arim.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certify that In the person
In anf tha nner we s to become rmit is
issued,the
1 shake not employ any Demon In any manner ao u to tierome eubjuct m the
Worlici m
CompenRan laws of CallfornbWATER SYSTEM/
. Date TREATING PAID
O Z Applicant - NEW RESIDENTIAL PLMB,_,SQ.Ff. Date Recei t#
Z 0 NO'DCETO APPLICANT.If,after making this Certificate of Exemption,you
should bemmesubject to the Workers''Compewllon provision ofthe Labor TOTA
It W Code,you=at forthwith comply with such provlsloce or this permit shall be D
W G BUIL ING FETE
deemed revoked, - _
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm shat there b a mmtmcteon[ending agency for the perform ELECTRIC FEE
Z ance of the workfor which this permit b issued(Sec.3097,Civ.C.) - TOTAL:
U 0 Carder'.Name PLUMBING FEE
ly Iendre.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW - Icertlfythat i have read this application and statethat theaboveenformatlon
C Ie correct.I agreeto comply with all cityand countyordirunces and statelasys PERMIT ISSUANCE, FEES PAID: ,
�.' relating tobulldingcorutroctlon,end Wrcbyaulhorlu rcpresentativn ofthti
[•- 2 city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADDTO MECH. Date Reeei [#
V — (W agree to save,Indemnify an d keep hurnius the City of Cupertlro - -
agai liabilities,judgments,cosuand expenses which may In anyway accrue AIRHANOLINC UNIT CTO 10,000 CFM) SUBTOTAL:
ag tuld Cl In ronsequence the entire of the.permit.
�'�y AIR HANDLING UNIT(OVER I0000CFM) CONSTRUCTION TAX
Sigu,atm of Appiteart/CorlInctor JData INHAUS'r How(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or futurebullding occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Reuel t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
Healthand Safety CedeeSSectm.255320)? HEATING UMT(OVER 100,000 BTU) JV ,TOTAL: L
❑YonM No ay �/�
Wllitheapplicant or future building occupant use equipment ordevlces VENTILATION FAN(SINGLE RESID) ISSU mlE DA'Z'E
which emit havrdousalr contaminants..defined by the Bay Area Air ry 9
Quality Management District? MOILER-COMP C)HPOR 100,000 BTU) �. O
4 Yn, No Q
have read the hazar our materials requlremenh under Chapter G95 of BOILER-COMP(OVER 100,000 BTU) a ! as
'the CalilamiaHualthASrfety Code,SenWm25%5,25533and2553p.1 C,4.
.understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECIL SQ.FT /'/
- responsibility to notify the occupant of the requirements which most be met
prior to Imus oce of a Certificate of Ocaupa my.
Owner or authorized agent Date
TOTAL: 155IR5DBY: �� s`'�
OFFICE COPY