23207 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ed Identification PERMIT NO.
Building Address: 23207
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nere ante: one:
A A A
ie D W n2 S'1 CITY OF CUPERTINO-BUILDING DIVISION
Cant rs Name: 1. a: APPLICATION / PERMIT
BLULDINGELECTRICALPLLJ.MBINGMECHANICAL CATEGORY CONTROL N
Architect ginmr: Lk.No:
Y09 gQn. ELECFRICPERMIT FEE BUILDING PERMIT INFO
2 2 Sa-R ct.7'D CQ �ECI PLUMB MIC
a�ai.0
Add sa: Qgr k PERMITIS5IJANCE .�• ❑
LICENSED CONTR CTOR'S DECLA
m, RATION
I hereby affirthat l am licensed under powidons of Cha pier 9(mmmenc APPLIANCE-RESIDENTAL JOB DESCRIPTION
homseIng h to ection
000 and of
o(the Business and Professions Code,and my � �
license la In lull and dfM. �v PANELS
Limn ass�Co tr 97JN
ContndorUP TOM
ARCHITECPSDEC RAT, N 701-1000AMPS
DCo I understand my plans shall be used as public records. QVERI00UAMPS ,FT, 5A S/cSQ.Pp. .
z E Limned Professional SIGNSELECTRICAL
<� OWNER-BUILDER DECLARATION
I-, Thereby afRrenthat]am ense exempt from the Contractors Liclaw for the -CULCBiCL11T/MLSC
O0...� following reason.(Section 7031.5,Business and Professions Code:Any city or TEMP METLA ORIOLE INS(. DATE
ZMg� cauntywhlchrNukesapermittocomtrua,alter,knpmve,demolish,orrepair
g ,a,1.0 6c anystrudure pdorto its issuance,also requiresthe applicantforsuch permit to POWER DEVICES
NO a file a signed statement that he is licensed pursuant to the provi dons of the
3 01~n Contractor's License Law(Ctapter 9(commencing with Sedlon 700)of Divi-
slSWIMMING POOL ELECTRIC on3o(the Buslnersand Pmf.n .Cade)orthat heisexempttherefromand VALUATION
Q the Gash for the alleged exemption. Any violation of Section 7031.5 by anyOITILETSSWITCI-IFSHXTURFS
applleanlfora permit subjects the applicant to a civil penalty d net room n
c. five hundred dollars he pr. NEW RESrDENTIAL ELECTR SQ.Ff.
•'�n ❑e as owner ll the property,or my employers with wage as there mk STORIES TYPE CONSTRUCTION
com(Sec.7lon,Btial othe us a rid k,anssicn.rudure b not intended L offered for
sole 03ee.apply
to alnowandf propslom Code:The Contractors Llcenu law
$ don not apply to an owner of property who builds or improves thereon,and
whodoeentssuch work Nm Bodoraugh his own employees,howevr,thebilding or OCC.CAOIIP AIS.UNITS
-
Improvements am intendedoroffcredfor sale.mt ho neer-buflderwW have T �1
Improvementlawld withlnone)earofcompldbgtheowner-bullderwWhave
(4t.lIurden of proving that he did not build or improve for purpose ofsale.). QTY. PLUMBING PERMIT FEEFfADDZA:YE APN
Lj 4 as owner of the property,am exclusively contracting with limned PERMITt55UANCE
contrtdoa W eaectrud the project 4
(Sec.7W,Businessland Profersioris Code: ►�
The Cormcdor'e License law don not apply to sr,owner of property who ALTER-DRAIN builds or improvcontracts,eon, and who contrafor such pLo - AIN&VENT with a WATER(EA)
co,R(faelor(s)licensed pursuant to the Contridors Lkerue Law. FEE SUMMARY
LJ 1 am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE
Owner to DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
-. WORKMAN COMPENSATION DECLARATION RECEIVE
01 hereby affirm that I have a certificate of consent to self-Insure,or a FIX'EURFS-WINC.40UTTm
-e-. SC iOOL TAX Y N
certificate of Workers'Compensation Insurance ora certified copy,thereof(See. RECEB'T N
3800,Iab C.) GAS EAUTTm PARK FEE Y NPoilryp GASid SA) RFlEB'IN
Camany tlU1LDINC DIVISION FEES
[�C"Ified copy is here with the ed,city GREASEANINTERCEPTORPLANGHECK FEE
�Cellled copy V(Old with the city Ivpedion divialon.CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRPAIDCOMPENSATION INSURANCERhbaed"m need not becompleted lithe permit bforonehundred dollars SEWER-SAA.2ooFT. Date Receipt#
(Si 00crolyt.) WATER HEATER W/VENT/ELFCTR ENERGY FEE Y N
I cert. that Ntheperformanceof thework an as t bthla permitla Ended,the
I shall not employ any person in any manner m v to become subject to the
Workers'Compensatlon laws of California.Date WATER nS-I1M/rnEAn NG PAID
C• Z Applicant
Z O NOTICE TO APPLICANT:IL aker making th6 Certificate of Exemption,rovisions ofthe you NEW RESIDENTIAL PLMB. SQ}T. Date Recei [#
~ N Labor —
Code,You=at fortshould become hwithto tco ply with such provisionrnation s orthis permit shall be TOTAL:
LU > dermed revoked. BUILDI G E
t1 O CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyafRrmthst there Is a constructor,lendingagenry forthe perform- T ELECTRIC FEE
7 Z ance of the work for which this permit is issued(Sec.3097,Civ.C.)
U O tender.Name PLUMBING FEE
LL H Lrnder's Address QTY. MECHANICAL PERMIT FEE
O W 1 unify illicit have read thisappbeatlonand natethat theabove information MECHANICAL FEE.
S ismrmd.l agree to comply with all city and county,ordinances and state laws PERMITISSUANCE FEES PAID:
} reiating to building construction,and hereby authorize representatives ofthla
[— Z city to enter upon the above-mentionedproperty for Wpection purpeam. ALTER OR ADD TO MFCH.
(We)agree to save,indemnify an d keep harmlee the City of Cupertino Date Receipt#
against liabilities,judgments,ormand expensnwhichmayi .rJewayacvue AIR HANDLING UNIT CTO 10,000CFM)
agaire sal ity In consequencearch gr, ting of this permit. SUBTOTAL:
AIR HANDLING lAvTT(OVER 10,030 CF11) CONSTRUCTION TAX
Applicant/Contractor /Date ! EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
W0 r.il the"pplkant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.1$and the Date Recel t#
Iicalth and Safety Code Section 25532(")7 HEATING UNIT(OVER 100,000 HIM TOTA
❑Y. M No 10
Will the applicant or future building ompant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haraidoua air cont"minae as definN by the Ray Area Air
Quality Management District? BORER-COMP OHP OR 100,IXD sill) py A B
C?Yn ❑No 11� s'Y
, read the hazardous materials mild torments under Chapter 6.95 of BORFR-COMP(OVER 100,000 BTU)
the Glifernla Health&Safety Code,Sections 25505,25533 and 75534.I
understand that lithe the
not erequir hsoctsw which
that it Is my NEW RESIDENTIAL MECH. SQ.FT JAN 21 �9
understands to notify the ongdoes ofthemently have awMchmost be met rn
prior to Issuance of a Certificate of Occupancy.
IyU-
Owner or authorized agent Date CITY OF CUptt,'
TOTAL: ISSUED BY: v
OFFICE COPY