23790 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project IdentificationPERMIT NO.
Building Address:
7 0/ it � �1 ni 23790 _ .
cors ante: //77 one:
1"",e 6 YAl CITY OF CUPERTINOBUILDING DI VISION ��y�y
lc--.
t .Name: Jie.Na: APPLICATION /PERMIT `•�.uN�a'7 Y✓�'T� BUfLDINGFI.ECTRICALPLUMBING-MECHAMCAL' AONIROLN
rchitect/Engtrmer. Lk.No:
/ A Qry - ELECTRIC PERMIT FEE. BUILDING PERMIT INFO
Add.-"/,- ,Sv 1/L L 14e, S'�• PFRMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby afOrmthat lam licensed under provdi^nsof Chapter9(commere APPLIANCES-RESIDENTIAL ] BDFSC ON
Ing seh S1.ion7000)of Divblon3 ofthe Buelnessand rofenionsCode,and my 1-76 �
Bcense it.In ion and effect. PANELS
Date CnotnRor H s)(ti -
ARCHITECT' ECLARAiI N 20140MAMPS
O% I understand my plans shall be used act public records. OVER 1000 AMPS.., SQ.Fr.FLOOR AREA $/SQ.FT.
O AGNS ELECTRICAL
Licensed Professional ,
<su OWNER-BUILDER DECLARATION
G]F7
F � Ihereby afOrm that latm exemplfromthe Contractor's License Law for the SPECIALCIRCUIT/MLSC
following reason.(Section 7mt.S,Business and Professions Code:Any city or
O s'ugquyy rountywhkhrequiresaper ttowmtma,altertrnpmve,demolbh,orrepair TEMP.METER OR POLE INST.
anyatm=m prlortolle tsaunce,also requlreatheapplicant for such permit to POWER DEVICES
Vfile a signed statement that he b licensed pursuant to the provisions of the
Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi-
O w I"n R SWIMMING POOL ELECTRIC
30 sion3olthe Buainessand ProfessionsCode)orthat he b exempt therefromand I' VALUATI
' the hi.b for the alleged exemption. Any violation of Section 7031.5 by any
OVILETSSWI'ICHESFl%TURES D O
�i appBomfora permit subject/the applicant roe civil penalty of not nnrctlun
p. livehundred dollars(SSM. NEW RESIDEMIALELECTR SQ.Fr. STORIES TYPE CONSTRUCTION
n1,as owner of the property,or my employees with wages as their sok
k./Q compensation wllldo the work,and thestructurc is not intended or offeredfor
,V0 sale(Sec.7044,Bogreas and Professlons Code:The Contractor'.License Law
does nM apply to an owner of property who builds or improves thereon,and OCC.GROUP RFS.UNITS
EE whadassurli.mkMmselimthr^ugh hisawnemployen,provided thatsueh
improvements arc not intended oroffered forsale.If,however,thebullding or - TOTAL: -
Improvement"old withinoneyearofcomplMion.theowner-bWlderwill have r
t rden of proving that he did not build or improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
UL as owner of the property,am exclusively contracting with licensed I'FRMR ISSUANCE
contractors to construct the project(Sec.7044,BusNea and Profenlom Cade:
The Contractors License Taw does not apply to an owner of property who
wALTER-DRAIN VENT-WATER[EA)
builds or Improve.thereon, and who contracts fns.ten ptoject.with a FEE SUMMARY
co,foBl[yactor(.)Ilmesed ec pursuant to the Contractor's License Law, BACK FLOW PROTECT.DEVICE
0I am exempt under SB A P C for this reason
. - DRAINS FLOOR ROOF,AREA,GOND.
SANITARY Y N—
a
`r Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FLCIURES-j'ER TRAP SCI{OOL TAX Y N_
❑T hereby affirm that I have o Insurance
of consent m op the RECEIPT N
3800,Lab of Worker'Compensatlonlnsurance ora certi(kd copythemof(Sec. GAS EA.SYSTEM-1 INC<OUILETS PARK FEE Y N_
3800,Lag C.) RECEIPT N
Pdky p GAS EA.SYSTEM-OVER 4(EA)
Colicy N BUILDING DIVISION FEES
I�Certlfled copy is hereby filed
the city
GRFASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy b filed with the tlty Inspection division.
CERTIFICATE OF O(EM PTTON FROM WOR KERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANTIARY-STORM FA.200FT. Date RCtt'1 IM
(TFissection need not be completed if the permit b for ane hundred dollars
($100)or len.I WATER HEATER w/V[M/ELECTR ENERGY FEE Y_ N_
I certify that in the performance of thework forwhich this permit talented,
I shall not employ any person in any manner eo as to become subject to the WATER SYSTEM/TREATING
w.ekeri Cnmpen.atmn Laws of CaI foml..Date PAID
APplicanl Date Recei t#
2 NEW RLSIDENITAL PLMB. SQ.FT.
Z O NOTICETO e..bje t to
after making m enCeion pro is Exemption,Labor
Code, ou most
subject to the Workers'Compensation pmvbioro of the Gbor - TOTAL'
F— N
Code, el forthwith comply with.uch rovisknsor thio rNt shall be
� j aeemea re�ol;ea. py p � BUILDING FEE
LU — CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL G Ihereby affirm that there b a cormtmctitn lending agency for the perform TOTAL: ELECTRIC FEE
7 Z ance of the work for which this permit b luued(Sec.3097,Civ.C.)
V O Lenders Name PLUMBING FEE
H Lenders Address QTY. MECHANICAL PERMIT FEE
LL U Iced ify that l have read this application and state that the above Information MECHANICAL FEE '
ow Is correct.l agreeto comply with all city and county ordinances and pate laws PERMIT ISSUANCE FEES PAID:
>. M relating to building construction,and herebyaulhorlurepersentallvnofthb
I" N city to enter upon the above-mentioned property for inspection os
on purpe. ALTFRORADD TO MECH.
Z (We)agree to save,indemnify an of keep harmless the City of Cupertino Date Receipt#
V against liabilities,judgments,coslsand expenses which may In any yaccrue AIR HANDLING UNIT CTO I0,000CFM) SUBTOTAL:
agalrts C 1 nsolybnre of the granting of thl.perytit
AIR HANDLING UNIT(OVER IO,OW CFbD CONSTRUCTION TAX
Sigfisture ofAplicant/Contractor Date EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haaardous HEATING UNIT(TO IMODO BTU) Date Recel t#
.tie lasdefinedbytMCupertino Municipal Code,Chapter9.12,andthe
Healthand SafetyCode Scofo,255324)9 - HEATING UNIT(OVER 100,(300 BTU) TOTAL:
❑ Yen • No
-Which
the applicant'orfuture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE Pf p ' D
which emit harardous air contaminants as defined by the Bay Area Air T A
Quality Management District? BORER-COMP 6HP OR 100,000 BTU)
�1�II Yes, F�No Q
Thavereedl ealth&r'3om materiae requirements 25555533 and 255 . I of BORFR.COMP(OVIIIt l00,000,BTUI JUN e9 19�C
theunderstad that if the building
Code,Sections haven 3and25X. I - a• k7 C
respostandthat notify the occupant
of t errenirvere is which that homy NEW RESIDENTIAL MECH. SQ.IT r'
mporuibilitymndify theampant of the requimment.which most be mel CII �, vVr'.t{I Illi.
phorm Lssuanaofa Certify teofOmrpancy. ,R//�k
ls:lhr
Owner or authodh TOTAL: /dagent Date ISSUED BY: �r 1
OFFICE COPY
' l