23677 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Preect Identification PERMITNO.
Building Address: 23677
I _)s, 31On'R e. _ No
o e: '` A A
O �i-`- case - SS�d�Y CITY OF CUPERTINO-BUILDING DIVISION �j -7
_ C t e.. Name: I nu=.Ngo: APPLICATION /PERMIT �3 / L
J /—U 4� N 255/7S BUILDING-ELECTRICAIIPLUMBINGME MCAL CATEGORY CONTROL N
Architect/Engineer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
I Wit
Address: PERMITISSUANCE ❑ F-1 11LICENSED CONTRACTOR'S DECLARATION
lh mbyaffkmthallamlkemedunderpro Wmsof Chapter9(corunenc APPLIANCE�RRSIDENTIALJOB D[SCRIFFION
ingwith5 ion7000)af DIWion3ofthe Buslnessand Prcf.I...Code,andmy
license is in fup once defied. n PANELS C I L1',V7T +y.1� /y
Date17f Contratmr +�!/
ARCHITECTSDECLARATION OVER00 AMPS
ss0 2 I understand my plans shall be used ns public records. OVER 1000 AMPS SQ.FC.FLOOR AREA E/SQ.F7.
OCC
ztj Licensed Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC LED IN
OLp,, �Q Iherebyaflmn that l am exempt from the Contractor's Limes law for the -
ZFWfollowing reason.(Section 7MLS,Business and Professions Code:Any city or mTEMPMETERORPOLEINST. \ n I T R
r IllW cauntywhichrequlmsapermittocomtmMtt tegimpmve,demlbh,orrepair 'A 4,J 1 � •
.l anystctum prlorto its Issuance,also requltesthe appBesnt fursuch permit to POWER DEVICES rJ
.� Com.
ilk a signed statement that he is licensed pursuant to the provbions of the — '7 31
04 Contractor'sLicense Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC DATE 3oN 0 sion3ofthe Businessand Professbra Code)orthathebexem therefromand
the basis for the alleged exemption. Any violation of Section 7001.5 by any OUTLETS—SWITCHES-FIXTURES
o Gn^
DO applicant for a permit subjectsthe applicant to a civil penalty of net morethan 5co
o. five hundred dollars(5.5001. NEW RESIDENTIAL ELECTRRF.
7< � willI,as owner of the property,or my employees with wages as their sole STORIES TYPECONSTRUCTION
compensation,wdo the work and the structure Is not intended or offered for
9 O sale(5ec.7014,Busteess and Professions Code:The Contractors License Law
$� does not apply to an owner of property who Wilds or improves themes,and
OCC. RES.UNITSwho does such work himself or through his own employees,provided that such
unproverrents are not Intended oroffered forsale.If,however,thebuilding or TOTAL:
improvement issold withinoneyearofcompldtb theowner-builderwill have
tljL]lurden of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
u 4 as owner of the property,am exclusively mntnRing with IkensM PERMTT ISSUANCE -T
contmtors to censtruct the project(Sec.7074,Business and Professkns Code: - (l
The Contractor's License law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EAI
builds or Improves thereon, and who contracts for such p(njects with a FEE SUMMARY
d
gnBactor(s)licensed pursuant to the Cmtradorb License Law. BACK FLAW PROTECT.DEVICE
LJI am exempt under Sec B &P C for this reason
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,CON I. SANITARY Y_ N_
Owner Date RECEB'f Y
WORKMAN COMPENSATION DECLARATION pD(TURES PER TRAP SCI100L TAX Y_ N_
caner affirm that 1 have a certi0rate of consent to self-Insure,ora RECEIPT N
certificate of Workeri Compervatlonlnsinters ora emli0ed copythacof(Sec. GAS EA.SYSTEM-1 INC.4OUTLETS PARK FTE Y N
35Eo,lab C.)/d 13330—°/ L
policy YDING DI p
. Cn�any-,Sf�� GAS E.A.SYSTEM-0OVER BUILDING DIVISION FEES
CcAlfled dopy is hereby furnished. GREASE/WDUSTRLWASTEINTEItCEPTOR PLANCHECK FEE
[DQ61 ied copy is filed with the city Inspection division.
CERTIFICATEOFEXEMPFION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM E.A.W0FT Date Remi t#
(Thissection need not be completed if the permit b for one hundred dollars
($lOWorless.) WATER HEATER W/VENT/E.F-GTR ENERGYFEE Y_ N_
1 certify that In the pcdomunm of thework forwhlch this permit is bsued,
I shall not employ any person in any manner m ss to become subject to the WATER SYSIFM/TREATING
Workers Compensation Laws of California.Date PAID
OZ Appll.et NEW RESIDENTIAL PLMB. SQn. Dale Recei I#
Z O NOTICETO APPLICANT:ILaker nuking this Certificate of Exemption,you
should become subject to the Workem''Compematlon provisions of the Labor TOTAL:
N Code you must forthwith comply with such provislons orthis permit shall be BUILDING E
� j ded revoked.
W eem
— CONSTRUCTION LENDING AGENCY SEISMIC FEE
d I hereby affirmthat there Is a construction lending agency for the perform TOTAL: ELECTRIC FEE -
7 Z seen of the work for which this permit is issued!(See.3097,Civ.C.) ..s PLUMBING FEE
02 Lender's Name
f- Landes Address Q'rY. MECHANICAL PERMIT FEE MECHANICAL FEE
LL O ImrtlfythatlhavemadthbappUmtionaedstatethotheabovelnfomutim
O W is corted.Iagree to comply with all city and countyordinances and state laws PERMIT ISSUANCE FEES PAID:
} 1 relating to building c nstrution,and hereby authorize representatives of this ./�J1-(a
t Z city to enter upon the Above-meatloned property for inspection purposes. ALTERORADDIDMECH.
(We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Reecipt#
V
a liabilities,judgments,costa and expenses which ma In anywayaceroe AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL:
at
aald Cityln e 7/
f the granting of this pct it.
AIR HANDWNG MIT(OVER lO,WOCiIf) CONSTRUCTION TAX
Igoo I t/Contractor Date EXIIAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
aure
HAZARDOUS MATERIALS DISCLOSURE
Will th Pplkant or future building occupant store or handle hazardous HEATING UMT(TO100,000BTU) Date Recei t#
mover al as defined by the Cupertino Municipal Code,Chapter 9.12 and the
I ieahh and Safety Code Section 2SS32(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: .�
❑Yes In No
Will the applicant orfuture building occupant use equipment or devices VENITLATION FAN(SINGLE RESID) ISSUANCE DATE
which sent hamrdous air contamimnts as de0ned by tet Bay Area Air
-� Quality Management District? BOILER-COMP(311POR 100,OM BTU)
Yes No
have read the hazy esus materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,"BN) B
the California Idealth&Safety Code,Sedlons 25505,25533 and 25534. I D
understand that if the building does nm currently have a tenant,that it is my NEW REST DENIIAL MECH. SQ.FT
responsibility to notify the Deco pant of the mju lmmenta whkh must be met fill
prior to Issuance of a Certificate of Occui pansy.
Owner or authodud agent Date ISSUEDI1Y:UI I
TOTAL:
OFFICE COPY