23657 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Address: 23657
'I36r7
( Dicik
(Jwner one:
CITY OF CUPERTINO-BUILDING DIVISION
Contvlor's N��a�rn�,�: // Lie,No: APPLICATION /PERMIT -
�"~� WNEI.. BUILDINGELECTRICAL-PLUMBING-MECHANICAL CATEGORY CONTROL
Architect/Englneer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
AddMsc
PERMITISS(IANCE � ❑
LICENSED CONTR under SDECLARATION
IM1ereby thsoot firmthat[amg.3.fth.B.d v .dloffh..0(mmmanc AIPI'LIANCFSRUSIDENML OB DESCRIPTION
ingweh in
7000)Oto.
ltho BuYweaand ProfeselonsCode,mdm ^ % ,
license is In fug loco and effect. PANELS
Lineae Class Llo/
Date ConlnctoroFe
—UP TO 2DOAM
o AIT
RCHECT`S DECLARATION 201-IODO AMPSP tzs-1 T
rx0O ]understand my p6wehaBbe used an records OVER 1000 AMPS �SQ Fr R� �offEA' � `.9/SQ.FT,
(Ideas.I��j Licensed Professional SIGNS ELECTRICAL /1 ppp'���
OWNEReBUILDER DECLARATION SPECIALCR(CUIT/MIST /, UTE R
z � hemby at(I mtOEVNE exempt ER the DECLARATION
censs loo fa the CM1
oo fogawlsg reason.(Sectio 7(31.5,Business and Professions Code:My city or
OZ•" which TEMP.ME[ER OR POLE INST. II//�
F, muntycture prqulma permiIssuattoconstwct,as theaplicatdemolish,for so&
orret to ` 7
any stmcturcprkubits hat heirnce,Wo sed pursuant t the rovisinsof to POWER DEVICES
file a signed Ycens eLa that he b licensed pursuant to the provisions of the �--
Ow� Cor3oftr's License w'mifeaer9(mnercncing with eIsexacticm mpttherefof and
30 Yon3o(the Business end Prdessbw Code)orthal he bexe therefromaM SWIMMING POOL ELECTRIC VALUATION
the basis!or the alleged exemption. Any violation of Sectbn 70115 by any
{aS< applIcantfora permit subjedatheappllcanitoa civil pewltyofnm moretrum OII7LETSSWITCHESFI%'I71RE5
liv as owner ed of
the property,
NEW RESIDENTIAL ELECTR SQ17. STORIES TYPE CONSTRUCTION
ationGGGGWW1711yg Ser I,aeownerli theproperty,orhe employees with wages r offered dole
F� m.70Kwllldothewormfmihe Code:rehe Contat tendedo License
Law
❑ sale(Em.7644,to alnowand Professions Code The Contractor`s License Law
S$ woecotapply loan imse ofproperty who builds orImproves thereon,and OCC.GROUP RES.UMTS
whoow ..ttw. rkhimeeded.raughhiaowale.Ify eprovidedthataum
Improvementsarenal Intended earoimd Elsdon.ILhowever,tMerwdingve T
Improvement le mid within one yraro(compldlon,the owner-bullderwlll have
t rd en of proving that he did not build or improve for purpose of vie.). QTY, PLUMBING PERMIT FEE FTOODTDNE APN
Lj L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractorsto mnsWct the project(Sec 7044,Business and Professions Code:
The Contractor's Llmnee Law don not apply to an owner of property who ALTER-DRAM&VENT-WATER(EA)
builds or Improver thereon,and who contracts for such ptojecH with a
_ �gIB(edor(s)u ancipunuanttothe Contractor's License Law. FEE SUMMARY
Liam exempt under Sec B k P C for this means BACK FLOW PROTECT.DEVICE
DRAINS FLOG R SANITARY Y N
OUTSIDEFEES
Owner Y Date R ROOF,AREA.GOND. RECEIPT M
1 WORKMAN COMPENSATION DECLARATION V FIXTURES PER TRAP O �� SCHOOL'TAK Y N
❑I hereby affirm that I have a certificate of consent to self-Imurc,or a RECEIPT
8
certlllcate otWorkeri Compensatlrnlnsuranm ora certified ropythemof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS ��• PARK FEE Y N
3803,lab C.) t
Policy N_ GAS EA.SYSETM-OVER 4(EA) RECEIPT If
Com any BUILDING DIVISION FEES
Certified copy is hereby te city WASTE INTERCEPTOR PLANCHECK FEE
Certified copy is Ned withh the
dry e inspection division. -
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID
v
COMPENSATION INSURANCE SEWER-SANITARY-yTnaM EA.20OFi, Date Remi t#
(Thlscilon need not be completed If the permit V fnons hundred dollen
(f1I6)ofythat - WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Iacut employ
any he
mannerhe.cuk so as
lhle permit is to theed, —
I hall not employ any p In any manner at u to n� mtb)ect to the WATER SYSTEM/TREATING
Worken'Compensatiorytgias/nw�cal rni..Data 4114�4T- PAID
0 Z Applicant I it s �' -
Z NOHCETO APPLICANT.If,after making this CertBicale of Exemption,you NEW RESIDENTIAL PLMB._SQ.Ff. Date Rece1 t#
ahold become subject to the Workers'Compensation provisions of the Labor TOTAL:
C N Code,you=at forthwith comply with such provisions or this permit shall be
1 deemed marked.
BUILDING
ILa CONSTRUCTION LENDING AGENCY SEISMIC FEE -
Z IM1ercby a(Orrnthal there isacomenadlon lendlegagenry frrthe pedareo- ELECTRIC FEE
0
anm of the work for which this permit is Wuea(SeT 'c.3097,Civ.C.) � 2
I<nder'e Name PLUMBINGFEE �-
LL H lender`s Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W emI crAlfythal l have read thisapplicallonand Yate that theabove information
fIrred.lagree to comply with all cityand county ordinances and Yate laws PERMIT ISSUANCE FEES PAID:
>. W relating to building mnstroction,and hereby authorize representatives ofthb
F Z city to enter upon the above-mrntoned properly for Inspection purposes. ALTER OR ADD TO MUCH.
— (We)agree to save,Indemnify an d keep harmless the City of Cu pert Ino Date Receipt#
against liabilities Pdgmente"..ad expenses which may In any weyaceme AIR HANDLING UNIT(TO 10,010 CEM)
age last said City In tnting o(thl ltSUBTOTAL: .
n �
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
gwtum of Applicat/Contractor Date E)CHAUSTHOOD(W/DUC) CONSTRUCTION TAX PAID:
HAZA R DOLS MATERIALS DISCLOSURE
Will the appH.at or future building occupant atom or hand le hazardous HEATING UNIT(TO 100,000 BN) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
Health and Safely Code Section 25532(a)2 HEATING UT(OVFR IW,"BTU) TOTA
r
T❑Yea u No
WOE the applicant orfuture building occupant use equipment or devices VENTILATION PAN(SINGLE BESIDE ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
silty Management District? B0ILER-COMP(3EIPDR 100.0(3 OT10
4 Yes he n No
haveread a nus Code,Se requirements 2555,25533 and 2S5r8.95 of BOILER-COMP(OV1R 700,000 BTU) p
the
understan thaHealth if the building Safety Cade,Secgons25ly have tenan75hat It A a
resontand Hut ntifytheoccupant
of to currently haves tenant,that it mot NEW RESIDENTIAL METH, SQ.Ff
responsibility to issuance
ce notify which must be met IWAY
prior to Lssuance ala CertlEcale olOccvpanry. � ^
Ownrr or authodzed agent Date ISSUUD BY:
TOTAL:
OFFICE COPY