23722 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
Building Pruett Identification PERMIT NO. t
Build Ing Add mas: 2'7_349 — �� ' 23722 n 3 n n n
wn�en" �sine: '�, U—�LY'R^-E G A / G. G
Wo Y/(/E' 7 (?/f?7— QqG=7r/ CITY OF CUPERTINO-BUILDING DIVISIONS1. )"2_1 �
Contractor's Name: Lic.No: APPLICATr ION /PERMIT
C BLRLDINGELECTRICALPLUMBINGMECHANICAL CATEGORY CONTROL N
Architect/Engineer. Lie,No:
QTY EL,ECTRICTERMIT- . 'FEE " BUILDING PERMIT INFO -Address: PEIMITISSUANCE T I )or .. El
CONTRACEOR'S DECLARATION Lf] o
I hereby affirmthat l am licensed under provisions of Chvpter9(comment, APPLIANCES-RESIDENTIAL - - JOBDE RRek741p{, ��
Ingwlth Saction7000)of Dividon3 ofthe BuslonnanciProfessionsCode,and my [} �.FF�V�ty��'0
license is In fuR force and effect. PANELS
License Cizss ' Lie#
Dale Contractor
ARCHITECTS DECLARATION 701-1000 AMPS
pkp�vv
N0z0 1 understand my plain shall be used u public remnls. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.Fr.
Fi E
Licensed Professional SIGNSHL
<<� OWNER-BUILDER DECLARATION SPECIAL &
7 � I hereby aRirm that am exempt from the Contractor's License Law forthe "
o following reason. 70115,Business and Professions Code:Any city or
O Z"� TEMP.ME O L
�4 county which requlresa permit toconsbuct,alter,Improve,demolish,arrepalr
irystracturepriectrits issuance,aborequlreethsappliontforsuchpermltto POWER f
rN1 5 file a signed statement that he Is licensed pursuant to the provisions of the _
3F Contractors License Law(Chapter 9(commencing with Section 7000)of Dial. VALUATI
FOS elon3o(the Buelnessand ProfemlonsCode)orthat heisnxempHhere(romand SW1MhBNG]'(IOL ELECTRIC ON
< the basis for the alleged exemption. Any violation of Section 70115 by any OfIILETSSWITC}ffSFIXFURFS cc)Wc,�)�
p ppRmnt fora permitsubjecotheapplicanitoadvll pnnaltyofnatmorethan S D640 4.
F IN adred dollars($SM.
W as owner ofthe property,or my employees with wages as their sole NEW RESIDENTIAL ELECTR SQ,IT, SPORIES TYPE CONSTRUCTION
C c, rap Edon,will do the work and the swRu re Is not intended or offered for '
O sale(Sec 7044,Business and Pro(essbu Code:The Contradors License Law
does not apply to an owner of property who Wilds orImproves therinn,and OCC.GROUT' RES UMTS
CC.. .bounce such work himself or through hlsown employees,provided that such
Improvemeets are net intended or offered for sale.If,however,the building or TO
Improvement issold withnnoneyearofcompletion,the owner-builderwill have
tF�,Vd.enof proving that he did not build or Improve for purpose of sale.), QTY, PLUM13INGPERMIi 'r FEE FLOOD ZONE APN
Lf I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCErontracton to ronstruct the projM(Sec.7044,Business and Professions,Code:
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN VENT.WATER(IU)
builds or Improves thereon,and who contracts for such ptojects with a
([+noRs)Licensed pursuant to the Contactors License Law. - FEE SUMMARY
I I am exempt under Sec B&TP C for this mason BACK FLOW PROTECT.DEVICE
Owner Date DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N_
• RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES-PERTRAP SCHOOL TAX Y_ N-
❑f hereby arthro that I have•,Insurance
of era
unified
to self-ihereof ora RECEIPT N
3800,ocniLaleolWorkeii Compsuatlon[nsurana oracertified ropylhereo((Sec. GAS EA.SYSI'FM-1 INCAOUTLETS PARK FEE Y . ,N
3800,Lab CJ
Policy N GAS FA.SYSTEM-OVER 4(EA) RECEB'T N
Cam any' B U ILDING DIVISION FE ES
['�Certmea copy is hereby tthe aty CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
' ❑CertlRed ropyis(Iled withh the city Inspection dlvislon. ,
CERTIFICATE OF EXEM PFION FROM WOR KERS' CREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date -Reeei t#
Rhissectnon need rad be romplcted lithe permit is forons hundred dollars
.. (310 amlyss.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I cent that o the performance In sof the work an as t cb co penult ctblued,
I shall not employ any person In any manner at u to become subject to the WATER SYSTEM/TREATING
Workare'Campensation laws of California. Date PAID
z Z Applicant - NEW RESIDENTIAL PLMB. SQ.FT. Date Recel t#
Z NOTICEco esubje AtotheWe7maklming tarid In.his lncal.Exemption,you -
ehouldbecomesubjecttotheWorkera'Campensallon proviste ofions of the Labor TOTAL:
; _ N
Code,you=at forthwith comply with such provinces or this permit shall be BO ��
W j deemed revoked. -
d G CONSTRUCTION LENDING AGENCY - SEISMIC FEE I
I hereby affirm that there is a construction lending agency for the perform- ELECTRIC FEE
V� O anceoflhe work(orwhichthis permit 6 Issued(See3097,Civ.C.) TOTAL: r PLUMBING FEE
Lender's Name -
IL I— Landers Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Imrti(ythatl haveread thbappliatlanand data that theabove information
iscorrect.Iagree to comply with all city and countyordinances and state laws PERMTTISSUANCEFEES PAID:
} S relating to building construction,and hereby authorize representatives oftht,
H 2 city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADDTO MUCH. Date Reeei t# .
— (We)agree to save,indemnlly an d keep harnless the City of Cu pen Ino - P
ago Inst liabilities,jtdgmentg mst�eand expenses which may In any wayaccrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agoln ski ty In cong`�a/��Re�J��,r ting✓✓ofthisparmit
- -4112�//6a- GG {9/ . Z AIRruNDUNG UNIT(OVER lo,000crM) CONSTRUCTION TAX
Sgnalure of plicant/Contractor Date EXILAUST HOOD(w/DUCT) . CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS III SCLOSURE "
Will the applicant or future building occupant store or handle hanrdous I MATING UNIT(TO I DD,000 BTU) DatC Reeei t
matcrlal as defined by the Cupertn no Municipal Code,Chapter 9.1 2,and the
Health and Sa(nty Coder.-Ssection 255324)? HEATING UNIT(OVER 100,0X0 BTU T
u1.
OTAL:
❑Yu No
Will the applicant or future building occupant uaeequipmentordevima VENTILATION FAN,(SINGLE RESID) ISSUANCE DATE
which emit haranlom air contaminants as defined by the Bay Area Air
Quality Management District? MOILER-COMP DHP OR 100,000 BTU
Yrs ❑No
1 hbyna ad the hic ousmatcrlals requirements underChapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California health&Safety Cade,Sections 75505,75533 and 25534. I PE I D
understand that lithe building does not currently have a tenant that It is my NEW RESIDENTIAL MECH. SQ.FT. Ir
r¢ponsibllity to notify the occupant of the requlmments which must be met
prior to issuance oft Certificate of Occupancy. MAY r+ 19 2
I
Owner Lir authoriud agent Data
TOTAL: ) `Y..
OFFICE COPY'