23018 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
B"°ding Addms: 23018
to3aLt
wnere ana: one:
I J (^(YYI , CITY OF CUPERTINO-BUILDING DIVISION
C
'drr.Name: LIe.Nn APPLICATION /PERMIT " Z `� ('
ik_a7 �q BUILDINGELECTRICALML BING-MUCIIAMCAL CATEGORY CONTROLM
Archlted/Engineer. Lk.Na:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addreav: POWTiSSUANCE .•� g �1�1 PLUMS MELEE
S ❑LICENSED CONTRACTOR'S DECLARATION L�1
I hereby affirm that l am licensed under provisions of Chapter 9(commen, APPLIANCES-RESIDENTIAL - JOB DESC N
IngwBhSen ail 700)anddiDivision 3o(Rhe Business and ProfneloneCade,and my
license IsIn ectall and died. PANELSLim
Data Clave LicCo N---mmon�. `
Date 1GHITEcr w�' 201IODOAM
ARCHITECT ECLA ION
Oa px ]uMeretand my pknsslaBbe used upub8cremrds OVER 1000 AMPS SQ.F(.Fl.ODR AREA g/SQ.Fi.
k Licensed Professional SIGNS ELECTRICAL
<< OWNER-BUILDER DECLARATION
G SPECIALCIRCNT/MISC
z.1.., Thereby,(limn that lam exempt been the Contractor's License Law for the
pO following reason.(Section 70315,Business and Professions Code:Any city or
O Z h TEMP.METER OR POLE INST.
�� muntywnkh rcqulresapermltrommtaun,alter,Impmve,dertnlLvh,orrepalr
qq anystructempriortolbbsuance,abo requImetheappllcantforsuchpermltto POWER DEVICCS
O Ole a signed statement that he islicensed pursuant to the provisions of the
O Contractors Lie..Law(Chapter9(commencingwith Semon 7000)of DWI- SWDAWNG POOL ELECTRIC
ekn3ofthe Bud nand Pmfmiam CWe)crthathei auniptthemfmmand VALUATION
the bash for the alleged exemptive. Any violation of Settle.7011.5 by any
applicant fora permit subjects more
the applicant to a civil penalty of not than OUTLETSSWITCIiFSEK'i'URFS ( f!J
five hundred dollars(SSM).
$I+" NEW AFSIDFMIALELECTR SQ.FT. STORIES TYPECONSTRUCTION
�r I,as,=lam
the property,or my employees with wages as their sole
compemation,willdo the work andlhe.tmcture is not intended or offered for
O .1.(Sec.7094,Businnsend Profession,Code:The Contractors Ll39nse Law
$ does not apply to an owner of property,who builds or improves thereon,and OCC.GROUP RFS,UNITS
EE who does suchwork himself or through hleown employees,provided that such
Improvementsarem Intendedorofferedfo ule.l(howevegthebulldingor TOTA
Improvement ksold within omyearofcomplebm the owner-W Oderw0l have
thLkurdenofpmving that he did notbuildorlmproveforpurposeofule.). QTy, PLUMBING PERMIT FEE pippD7ANE APN
uu I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE ��
rontrecton to construct the project(Sea 7094,Business and Professlou Code:
The Contmdors License Law does not apply to an owner of property who TER-DRAIN VENT-WATER(EA)
builds or improve,thence,and who mMract, for such p(ojecm with a ^—
c75ador(s)licensed pursuant to the Contractor's License Law. FEE SUMMARY
BACK FIAWI'ROTECT.DEVICE
_I I am exempt under Sec- B A P C for this mann
•
Owner ate
DRAINS FLOOR, A,ROOF,ARECONED. SANITARY Y N D
WORK MAN COMPENSATION DECLARATION BBC=#
SCHOOLTA% Y N
❑I hereby orke that I have o lmunne of consent d pytheurc,ora F7K7URE^'PFiR TRAP �a RECEIVE N
3900llcmeofWorken'Compeawllenluuranmora mrtlflM mpythenro((Sec. GAS EA.BYSFFM-11NCAOUTLEFS PARKFEE Y N
380q lab CJ
Pollryp BBC13ING sTX
Com any CAS EA.SYS(EM-0VERX(FA) _ BUILDING DIVISION FEES
ECertified copy is hercbyth the cid. GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
�Ce0lfled copy V llkd with the city Inspection division.
CERTIFICATE OF L7(EMPTION FROM WORKERS' GRFASE7RAP PAID
COMPENSATION INSURANCE Date
SEWER SANITARY
(fhlaenNion need nrt Immotpleted if the permit Is(mom hundred dollars STORM EA.71101T. RL'O01 tp
Icertify(ythat In the perlormanceofthewark(orwhkhthls permit ieleaned, WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
].hall not employ perave In any manner w u become uab ct to the WATER SYS77T1/TREATING
Worken'Com a we ofC llfomla.Date PAID
Q Z Applicant NEW RESIDENTIAL PLMB. SQJTL Date Remi tit
Z O NOTICETOAPPLICA aorkem'er ingthb ation p.i.i.Exemption,
..flh.!.b.
N Code,shoulomme forth i a cankers'such pmtliomortblonsoflhe Lab be TOTAL'
� ; Code,you must forthwith ply with such provkbm canthi,permit hall be BUILDING FEE
W dremed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a l hereby affirm that there is a mrutrudlon lendlegagenry,for the perform, ELECTRIC FEE
Z arm of the work!can which thin permit is Issued(See.3097,CW.C.) T�
(,) rx—
O Lender'.Name PLUMBING FEE i�
LL H Lender's Address - QTY. MECHANICAL'PERMITE MECHANICAL FEE rZ.
OW 1 mOifythatI have read this applicallonand statothattheaboveinfomatlon
1. Iscorrect.i agmto comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
co relating to building construction,and hereby authorize repreaentallvea of thin
Z city to enter nine show property for Inspection purposes. ALTERORADDTOMECH.
— (W save,Ind=fy an d keep hwrrdm the City of Cupertino Date Reeei tM
agai t 11 ,Odgmum.,"send expenses which may In any wayattrus AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agai ty In consequence of the granting of this permit.
C`1( � AIR HANDLING UNIT(OVER IO,WOCIM) CONSTRUCTION TAX
Sigaatur IAppllcan °mrador Date EKHAUs'(HDoD(W/DUCT) CONSTRUCTION TAX PAIDi
RDOUS MATERIALS DISCLOSURE
WII canlorfuture building umuNatsmre or handle himnious HEATING UNIT(TO 10),00 BTU) Date RCcej t#
material as defined by the Cupertino Municipal Code,Chapter 9.13,and the
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOT
❑Yea No
Will the applicant or tura building oduPart use equlpennt or devices VENTILATION FAN(SINGLE REBID) ISSUANCEJ?gT1�
which emit hazardous air contaminants.,de0ned by the Bay Area Air W 1
Quality Management District? BOILER-COMP DHPOR 100,0W BTU)
Yes
nave mad the hax.g. sNo
materlals requirements under Chapter 6.95 of. BOILER-COMP(OVER 100,000 BTU) NOV na�.
the Cellf.mat Health k Safety Code,Sedems 25505,25533 and 75539. 1 - ,7
understand that If the building does not currently have a tenant that It is my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requlremenls which must be met j
priorto Lssuanceof,Ceniflcateof Oecupamy. ca l of r
Owner m authorised agent Data ISSUED BY:. V
OFFICE COPY