23937 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
-- - Building Address: 15 23937
Ow NR Q2l°l2
one:
6�
ane: ACLS - CITY OF CUPERTINO-BUILDINGDIVISION A A
uc.N°: APPLICATION / PERMIT �� �Z
Architect/Engtomr. Lk.No: BUILDINGELECTRICALPLUMBINC-MECHAMCAL CATEGORY CONTROL M
i QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add.
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm
..70lha lamlicensed 3.ftheunder provtndPmfe sons 9(commem APPLIANCFSRESIDENTIAL JOB DFSC
Ingwlih Sectlen forces ddieon3 ofthe Buelussand ProfessloneCade,and my
license is In MU force and died. PANELS Mm
Lt...Cies, Lle.11
Date Contractor —UP TO 2DOAM5
ARCHITECT'S DECLARATION 201-1000AMPS
qaZO IundeRland lana shall W used.public records. OVER 1000 AMPS $/SQ FF.
q��uu my P W SQ.FT.FLOOR AREA
FZ��j Ltmnsed Prof..,..,— SIGNSELECTRICAL � ' _ ]1�� Iis
G<FFLLrr�yii
OWNER-BUILDER UILDER DECLARATION SPECIALCIItCU1T/MLSC V 4 �' & "�
7k., a thereby of rmthat l am exempt fromthe Contractors License Law for the n _
D i. fallowing rescan.(Section 7031.5,Business and Pmfesslons Code:Any city or gEMP METER OR['OLE INST. \1
F� =°untywhlchrNulreeapermittomrulr M.1ter,4 pmve,dem lLsh,orrepair /� {
any atrocture Priu�tostatement
itsIssuance,W is also sed mes pursuant t the fmvWo permit a POWER DEVICES y /��
rY1 Bk a signed statement that he t r 9(commencing
ening it the tion 70oru of the N
F•�OSQw Cun3ofthlhusneelaw(Chapters(mmmerthat with Section7erefmu0D)of Dint- SWIMMING IDOL ELECTRIC
tlon3o(IheBusiness and ProfenlomCode)orthat het exemptthere(romand VALUA'I70.
S° the basis for the alleged exemption. Any violation of Section 70315 by any
applicant fora perent subjectsthe applicant to a dvll penalty of not room than OUTLETSSWIT'CHESH)('IURES -
five hundred della.($500).� NEW RESIDENTIAL ELECTR^�n F1I,a9 owner of the property,or my employees with wages as their sole SQ.Fr. STORIES TYPE CONSTRUCTION
k7< compensation,wllldolhe work andthe structure is not Intended or offered for
5 O sale(Sec.7094,Bu.tress and Profession,Code:The Contractor.License Law
does not apply to an owner of property who builds or Improves thereon,and
C0.• who does such work himself or through Ms own employees,provided that such OCC.GROUT' RES.UMfS
improvement are not intended oroffered forsaie.If,however,ahebuilding or TOTAL:
improvement bsoki within one yearef e.ple0on,the owner-bullderwill have
t rden of proving that he did not build or improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE FI.ODDz NE APN
Lj{as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
mntmctom to corearuct the project(See,70K Business and profmioru Code: .r
The Contractor's Lime.e Taw does act apply to an owner of properly who ALTER-DRAIN VENi-
Wilds or improves thereon,and who contracts for such project with a ALTER- WATER(EA)
cg0.t[actor(a)licensed Paestum to the Contractor'.License Law.
ec FEE SUMMARY
LJ I am exempt under SB k P C for this reason BACK FLOW PROTECT.DEVICE
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
WORKMANCOMPENSATION DECLARATION RILE➢'(N
❑I hereby affirm that 1 have a Irt cone of consent to eoll-pyt a re,ora FIXTURES.PER TRAP SCITOOL TAX Y rf
3800,iLab m Worken'Comperwalonlreunna ora ttrtl(kd copythereo((Sec. RECm NN
Policy# C.) GAS EA.SYSTEM-1 INC40UILE15 PARK FEE Y_ N
Policy p RECEIPT N
Cn
GAS EA.EA.SYSTEM-OVER407A) BUILDINODIVISIONI'EES
rtieed copy trc
hereby
thecd
ed.
Certified copy t filed withh the Inspection division. GREASR/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Thissectienneed not Wcompleted If permit tfor one hundred dollars SFIVEItSANHARY-STORM EA.200FF. Date RCOCI t#
Of oo)orfy that
W W/VENT/F7,ECTR ENERGY FEE Y N
1¢not that Naho person In an theworkso as to become
is Issued,the
I shall not employ any person In any manner at u to become subject m the
O
Workers m
Cepensahon Laws of California.Dae WATER SYSTEM/ TING PAID
Z Applicant
_2U) NOTICETO comes'LICt tothe ageers'Comperation_Cxftlfl�le of
provis Exa ofthe ,you D[NT[pL PLMB. SQ.Ff. Date Remi [#
should become subject to the Workers'such prowbinprothl,t Borate Labor TOTAL:
~ (A deemedyou mwstforthwiah comply with such proWlom orthb permit shall be
� > deemed revoked.
W o �� BUILDING FEE
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
= Z Thereby work rm that
them tacorumuction lending 017,agencyCi(orahe perform. ELECTRIC FEE
once of the work for which this permit V Lowed(Sec.3097,Civ.C.) T
LL O l,ndera Nam PLUMBING FEE
IL f benders Address QTY. MECHANICAL PERMIT FEE
O W 1rned Iaree to rrxad comply wiapphcityndcungate y ordinances etate[aInformation MECHANICAL FEE
IL i moon t Iagreetocoanncti n,all ndtyandmthorun representatives
and stsotw, PERMIT ISSUANCE FEES PAID:
U) relating lobulWingcoeasuctlon,and hereby anithorlu representative ofahLs
Z ctytoemeruponlheabove-em.tk, property for inspection purposes. ALTERORADDTOMECH.
— (We)a w save,indemNfy an keep barrel.the City of Cupertino Date Receipt#
against Brie,' d rat,cote nse
whlcheraymanywayaorus AIR HANDLING UNIT(TO HLOXI CEM) SUBTOTAL•
ag.iro Cl o .ting m this permit.
AIRHANDLINGUNTT(OVER 10,000CIM) CONSTRUCTION TAX
Si Lure ppplicana/Conr or D EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSUI E
Will the applicant or futum building—Part store or handle h.,dou, HEATING UMT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date�No RCCCI t#
F-1 Y.Hexllh and Safety Code Section 75532(a)t HEATING UNIT(OVER 100,000 BTU) TOTA
Will the applicant or nature Wilding occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
v
which emm
it hammers air contamfearus.,defined by the Bay Area Av
Quality Magemem District? BOILER-COMP(310'OR 100,000 BTU)
?have
1�No
have read the hazar�Yi ons materlahrqulrem,entundered25531. 1 of BOILER-COMP(OVGR 100,0008N)
the California I Icalah h Safety Code,Section 25505,75533 antl 75539. 1
understand that if the building does not currently have.tenant,that it is my NEWRESIDENTIALMECH. SQ,FI' p
reaperuiblfity to notify the occupant of the requirements which must be met A #
prior to Issuance of a Certificate of Omrpancy.
dill
+l
Owner or aulhonaed agent Date I"
TOTAL: ISSUED BY: J.�/�'J+s7
LIIV
' bV("CYIIf(Y(J
OFFICE COPY