23865 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES USE BALL POINT PEN ONLY
—Building Project IdentificationPERMIT NO.
' Building Address:-:212 11 k � � p � � � 23865
s
neraName:, one:
DAVIO Go 0 K V IT G1-1 CITY OF CUPERTINO-BUILDING DIVISION
Contractor's Name: - - Lic.No:
APPLICATION /-PERMIT
15 BUE.DINGELECTRICALPLUMBINGMFCHAhICAL CATEGORY CONTROL X
Architect/Engineer. Lle No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE_ El �, ❑ ❑
LICENSEDCONTRACTOR'SDECLARATION - '
thereby affirm that am licensed under provlsleas of Chapter9(commmc APPUANCESRESIDENTfAL JOB DESCRR'110
Ingwlth Se ton70M)ofDivi.i.3ofthe Buainessand Pmfesslone Code,and my
license Is In fullforce and effect. PANELS u
Limnse Class ic.# +
Date—Contractor - B
ARCHITECTS DECLARATION ' a
201-1000 AMPSqjwft
otX Iunderstand my plansahaB be used as public records. I OVER IWO AMPS - SQ.FT.FLOOR AREA $/SQ.FT.
O
ZLicensed Professional SIGNSELECIRICAL r [" Q
6 OWNER-BUILDER DECLARATION _ - .1 E
ja] SPECIALCIRCUIT/MISC
IherebyafficrnthatIsm...mptfromthe Contractor's D I
License law(orthe
p followingreason,(Section 7031.5,Business and Profemlons Code:An d or
OZ t, Y city TEMP.MErMORPOLEINST, \t
p� countywhichrequlreaapermltWmmtmMalrer,lmpmve,de=hsh,ormpalr ag /o
a< a anystmu mprlortoibt ame,alsomquirestheappli=tforsuchpermitto POWER DEVICES ` 46 z.:
�w�U file a signed statement that he Is licensed pursuant to the provisions of the I
3u, Contractor'.License Law(Chapter 9(mmmeneing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
sion3 ofthe Business and Professlon,Code)or that he it emmpttherefromand VALUATION
6 S the basis for the alleged exemption. Any violation of Section 7Wl-5 by any OUTLETSSWITCHESFIXHJRES
O applicant for a permit subjects the applicant to a civil penalty of nor more than
dmllan(-5-50. _SQ}T. STORIES TYPECONMUCTION
�nrdred
sower of the property,or my employees with wages as their wleNEW READENT[AL ELECTRcation,willdothe work andthestructure it not Intended or offered for
ps7044,Business and Professioro Code:The Contractors License Law
d apply to an owner of property who Wilds or improves themes,and OCC,GROUP RES.UNITS
who does such work himself or thr ough Ms own employee,provided that such
improvements are not intended oroffered formic.If,however,thebulldingor T
ImprovemenHssoldwithlnoneyearofcompldiorytheowner-W Bderwillhave
tllLtiurden of proving that he did not Wild or Improve for purpose ofsaleJ. QTY PLUMBING PERMIT FEEFLOODZDNE APN
`J{as owner of the property,am exclusively contracting with licensed ppgMli ISSUANCE
contractors to construct the project(Sec.7044,Business and Profemlon Code: -
The Contractor.License Iaw does not apply to as owner of property who
builds or improve thermn,and who contracts for such p(ojects w!th a ALTER-DRAIN -WATER(EA)
cgRllecador(s)licensed pursuant to the Commeror's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
Ln I am exempt under S . B&P C for this reason
DRAINS FLOOR ROOF,AREA,GOND. - SANITARY Y_'N_
Owner DOUTRIDETEES
ate '
WORIC1dAN COMPENSATION DECLARATION RECEIIPT#
-' QI hereby affirm that I have a certificate of consent to self-Insure,ora 1D(TURFS-I'ER TRAP - SC79OOL TAR Y N
certificate of Workers'Comperwtlonlraurance or a certified copy themof(Sec. RECEIPT It
3800,Let,C.) GAS EA.SYSTEM-1'INC.4 OUMETS PARK FEE Y_ N_
Policy p RECEI
T
oany GAS FA.SYSTCM-0VER d(EA) BUILDING DIVISION
ISION FEESCCCertifed copy b hereby
h e
�Certiied ropy is flied with the efty Wpectlon division. GREASE/INDUSML WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
2WFI. Date Recei t#
(This section need net be completed 9the permit Is for one hundred dollars
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA
(EtID)am mires.) ELEC
] at In the performance of thework(arwhlch thio permlHS Issued, HEATER W/VENT/ TR ENERGYFEE Y— N—
I
—I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Worksrs'Compenmfion Lawaof Califomla. Date PAID
OZ Applicant
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,You NEW RESIDENTIAL PLMB. SQ.FE. Date Recei t#
f" should become sob)M to the Workers'Compensation provisions;of the Labor TOTAL:
N Code,you moat forthwith comply with such provision orchis permit shall be BUILDING 'E „
> deemed revoked.
'a G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hembyafftrm that there is a mnUudion lending agency for the perform- ELECTRIC FEE
Z anmofthework for which tial.permit L+beued(Sec.3097,CIv.CJ TOTAL:
OO Lender.Name PLUMBING FEE
LL Lenders Addree - QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O OJ Iartlfythelhavrmadthbapplicatbnandmatethattheebovelnformatlm
0. iscomed.I agreeto comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} relatingmbulklingcontruchmt,and hemby.min,rize representatives ofthle
F Z city to enter upon the above-mentioned property for Impecdon purposes. ALTER OR ADD TO MECH.
Date R2Cel f#
_ (We)agree to rove,Indemnify an d keep harmless the City of Cu pedino
against Babillties,judgmenta,cestaand pe se hichmay anywayaoaus AIRHANDUNGUNIT(T010,ODOCM- ) SUBTOTAL:
In conequence ng pe it.
AIR HANDLING UNIT(OVER 1Q000 CFM) CONSTRUCTION TAX
S me Applicant/Contractor f Date IXHAUSTHOOD fW/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardom HFAITNG UNIT(TO 1M0,000 BTU) Date - Recei f#
material as deBnd by the Cupertino Municipal Code,Chapter 9.12,and the _
Health and Safety Cade Section 25532(a)2 HEATING UNIT(OVER 100,ODO BTU) TOTAL
❑ Yea �I+��No
Will the applicant or future Wilding occupant useequlpmentmdevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined bythe Bay Area Air QNJ pp
Quality Marugement Distnd7 BOILER-COMPOHPOR 100,000 BTU) a`$ � #1
❑Yea EN-
J
shave read the hazardous materials requirement,under Chapter 6.95 of BOILER-COMP l00,0008TU) UJI/��
the Gllf.i.Health&Ssfety Code,Sedion25505,2a533and2S534.] ,I!
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT ^ lg9z
morto bibty to cenotityihe ofthe lmmentewhich must be met Cpy(Jr -`e0`�
prior to Issuance of Certificate o(Ocmpancy. L(/r
cn/uvu
Owner or authorised agent- Date TOTAL: ISSUED BY.7z�
OFFICE COPY