23439 (2) )
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PERMIT NO.
Building Address: 23439
$ /yl/nerar0 • 1�'S l�T =�i �
A
CITY OF CUPERT(NO-BUILDING DIVISION
cant*• '.Name: - qLic. APPLICATION /PERMIT ' 2
/a BUILDING-ELECTRICAL-PLUMBLNG-MECHAMCAL CATEGORY CONTROL M
Arch tett/Engineer.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:' S.r 96i PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(ro oamco- APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwith Sedion7000)of Drvikm3ofthe Buslnessand ProfeaslonsCade,and my
Ilanselain full eflect G PANELS
LlcenaeC am Lick 390 3� ���
Date
201-1
Cuntrador
ARCH[TECPS CLARATION 1100 AMPS
-
qOO (understand myplamshallb¢used aspublierecords. OVER1000AMP5 SQ.Ff.FLOOR AREA E/SQ.FL.
q��uu C4 / ,
tG tj LI...d Professional SIGNS ELECTRICAL C IN w 1
6 FLdu OWNER-BUILDER DECLARATION SPECLILCR2CUIT/MLSC G ,V
p, Ih.mbyaffirmthatI am exempt from the Contractor's License Law for the
Z °1 @ follo reason.(Section 70315,Business and Profeaions Code:An tl or R
OPyH� B y ry TEMP.METER ORPOLE INET. CA
R A
pppp� county mprioriwitsis amt alrutrueuasth, apliu;tfor ldi pe poo /4
yOy any atmduretatemelt.hat he Is alcensed ursuanppllant foreuch permitto POWER DEVICES r7 / �^�•
C
file a signed statement that he s licensed pursuant to the provisions of the
3n(� Contractors License law(Chapter9(commencing with Section 7000)of Dlvl- SWUIMING POOL ELECTRIC
O1 .1on3oflhe Busineasand ProresstotuCode)orthathesexempttherefromand VAL. O�O
Q'.�33 the bass far the alleged exemption.-Any violation of Section 7031.5 by any OUTLETS SWITC]IES}7XTURES �2 SO r
applicant fora permit subjects the applicant to a civil penalty of not nnmth..
five hundred dollars(5500).
R NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPECONSTRUCTION
cope as owner of the property,or my employees with wages as[herr sok
d for
mmpe c.70K Business
w P,%des the s Code:
The Contractors
ntract r o License
Law t
O sae(sec.apply
to alnm morn
Professions Code:TM C improve,Liceve law
$ does not apply to an owner of property who builds or Improves thereon,and OCC GROUP RES.(NITS
whodoements a arkhlmse Intended
or offered
miaow ale.If owe provider,the midithat such
Improvement is sold
sten dneyearrendfaletion the owevegilder, ill g orhave TOTAL:
Improvement saoldwithlnoneyearofcompldkrytheowner-bu0derwlB have I I '
tlg:,turden of proving that he did not build or Improve for purpose of sale.). QTY; PLUMBING PERMIT FEEpLOp zDNNE APN•
u L as owner of the property,am exclusively contracting with licensed 75 IT ISSUANCE
contractors to rorutmct the project(Sec 7044,Buelneas and Profession Code:
a The Cordele ore License law does not apply to an owner of property who
buildsALTER-DRAIN&VENT-WATER(F-A) ^
or Improves thereoNr and who contracts for such pt
ojects with aFEE SUMMARY
- cgRtfactor(s)licensed pursuant to the Contradea's License Law. BACK FLOW PROTECT.DEVICE
L..�I am exempt under Sec. 0&P C for this reason
OUTSIDE F
Owner Date
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
RECEIPT WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y_ N
❑1 hereby affirm that I have o certificate of consent g spytheure,ora RECEExf M
certi(lateo(Worken'Coompenatlonlnuranceora cedBlm copythenaof(Sec. GAS EA.SYSTEM-1 INCAOUTLETS PARK FEE Y N
Policy Mb CJ o�/g I ./ RECRUIT
I 7 �rC GAS EA.SYSTEM-OVER 4(EA)
Com anvBUILDINCDIVISION FEES
certified ropy Is heed with to city GREASE/NDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
�CHrtined ropy s neo with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP - PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 2lXIFf Date Recei tri
TThssection need not be completed if the permit sfor one hundred dollars
($100)or less') WATER HEATER W/VFM/ELECTR ENERGY FEE Y N
ce
I dify that In the performance of the work forwhlch this permit is Issued, —
I shall am employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING Workeri Compensation Laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB, SQd.7. Date Remi tp
Z O NOTICETO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workeri Compensation provisions of the Labor - TOTAL:
N Cade,you must forthwith comply with such provisions or this permit shall be
"Ui > deemed revoked. UiLDING FEE os%
CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 Iherebyafftrm that there his contructlan ending agency forthe perform TOTAL: ELECTRICFEE
Z ance of the work for which thin permit s ssued(Sen.3097,Civ.C.)
V O lamer'.N.
PLUMBING FEE
LL. H .Lenders Addms. QTY. MECHANICAL PERMIT FEE
O W lmdlfythatlhavereadthsepplimtionam statethattheaboveinformation - MECHANICAL FEE
IL es correct.iagmetocomplywith all cityand countyordlnarmsand gate laws PERMIT ISSUANCE FEES PAID:
>- W relating tobuilding construction,and herebyauthortim representatives of the _
H city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH.
Z
_ . (We)agree to save,Indemnify an a keep harmless the City of Cupertino Date Receiptfl
againtllabilitin,fudgtmrs,rods and expene.which may In anywayaomm AIR HANDLING UNIT(TO 10,000 CFM)' - SUBTOTAL
against said City In consequence of the gr fling of this permit :
- AIR HANDLING UNIT.(OVFR 10,000 CFM) CONSTRUCTION TAX'
wture amt/Contractor EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MA RIALS DISCLOSURE.R7y�f(�//�/
Will the appUe..t or future building occupant store or handle4azard6uB HEATING UNIT(T0100,000BTU) Date ReCel tilf
material as defined by the Cupertino Municipal Code,Chapter 9.1$and the
Health and Safety Code Section 25532(a)2 HEATING UNIT(OVER 100,000 BTIn TOTAL:
n Yes In No
�NIll the applicant or futum building occupant use equipment or devices VFNnLATION FAN 03INGLE MID) ISSUANCE DATE
which emit hasardous air contaminants as defined by the Bay Area Air
Iity Management District? , BOILER-COMP OHP OR 100,000 BTU)
C Lam, Yea F—I No
(have read the harn"Zous materials requirements under Chapter 6.95 of BOILER.COMP(OVER 100.000 BTU)
the CaI inert.Health&Safety Code,Sed ions 2550.5,25533 and 25534.I
understand that if the building does not mrmntly have.tenant,that it s my NEW RESIDENTIAL MFCH. - SQ.FT H23 1992
responsibility to notify the occupant of the requirements which must be met -
prior to Issuance a a Certificate of Occupancy..
CITY OF CUFtn 1IlluQ
Owner or authorised agent Data TOTAL: ISSUEDBY�5 1 •1
OFFICE COPY