23034 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project ldentlflotlan - - - PFRWT NO.
Bullet Address:. 23034 0 ^ A
5q0 ST G 3 4
sonar A A
+ ' ,,f I ,c ,q0b°t($'/ CITY OF CUPERTINO-BUILDING DIVISION
Contractors Nar�p q�l -ILu,J LIo No: APPLICATION If PERMIT
l/A1 IWf BUILDING-ELECTRICALML GING-MF LAICAL CATEGORY COMIROL a
y Architect/Engineer. ULIe.No: 11 '
'QTY1 )i 4 ' ELECTRIC PER1111T-t�r�,t + .FEE ' '.,!0.,tv BU1LDING,PER-MIT,INFO' t�`E.'
-_ - Address •y' / ' C/^5" PERh9TISSUANCE ! ❑ j •a
LICENSED CONTRACTOR'S DECLARATION `IJ
Ihambyafflrm that l am licensed under provisions of Chapter9(commmc- APPLIANCFSRESIDENCIAL JOB DESCRR'T[ON - /1
ingwit Seniors W
Divon3 ofthe Buam
neandProfcaaoneCode,and my
license
I �
ina in fu truce
and dkR PANES
Limn CUss Lk.asor� In�Y
Date Contractor UP TO 200
AMPS
ARCHITECTS DECLAR N
OZ^ I understand my plan shall be used as public records.� OVER1000AMPS SQ.FT.FLOOR AREA $/SQ.FT.
ww❑O❑Z`j LkensN Professional " SIGNSELECTRICAL -
GGGGGG
OWNER-BUILDER DECLARATION ..�
rn El " S['ECIALCIRCLRT/MISC
Z t'�� Ihereby affirm that iam axe mp[froromthe Contractor's License Law for the
loliowing reason.(Section 70315,Business and Professions Code:Any city or
rI"u� c°untywhichrNuiresa Ne tiomvtrun,alter,Impmve,dennlLh,orrepalr TEMP'M=OR POLE INST.
�a .n anysuucbum prior to its Issuance,also recta fres the applicant for such permit to POWER DEVICES 1 �� •�
file a signed statement that he Is Bcensed pursuant to the provislons of the
t, Contractors License Law(Chapier 9(commencing with Seddon 7000)of Divi- SWIMARNG POOL ELECTRIC '
HOS slon3ofthe Business and Professions Code)orthat Fels exempt therefromand E
Q the basis for the alleged exemption. Any violation of Section 7m1S by any OUTLETSSWITCHESI`DcT 1RES s '.
applicant fora permu subjensthe applicant to a civil penalty of nor more than
five hundred doll..($SM. a
�j 1,as owner of the property,of m employees with wages as their sole NEW RFSIDENTIAL ELECTR SQ.FE STORIES - IYPE CONS"FRUCTION'
compensation,wllldothe work andlhe structure lance intended or offered for
.1.(Sm 70K Buainessand Profattions Code:The Contractors License law
Q does not apply to an owner of property who Wilds or improves ehereoR and
S who doeswchwork himselforthrough hlsmeremployces,provided that such OCC.GROUP RFS.UMTS
Improvements am not Intended oroffered for sale.If,however,the building or TOTAL:
improvement issoldwithln evyearofcomp101b theowner-builderwill have
04.kurden of proving that he did notbupdorlmprovemrpurpossofeele.). QTY; i• ELUI4IBING PERMIT,Tr"" `•r !FEE
LI I,as owner of the FLOOD ZINE APN
Property,am exclusively contracting with licensed - PFRMTTISSUANCE
ThecunCdo.to constructtheLaw project(Sec.7044,applyBusiness and of pmpeHions Code:
The Contractor'soimpms the Law does not apply to an owner of property who ALTER-DRAIN VENT-WATER(EA)
Wilde or Improves thereon,and who tracads (a such ptoJects with a
_ ��WTador exempt under and to the Contranora Llmnee Law. - '' 1' ' '''FEE SUMMARYEFLES }•; ;
LJI am exempt under Sec. B&P.0 for this reason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR,ROOP,AREA,CONTI. SANITARY V N
Owner Data - ,. RECEIPT
N
spy WORKMAN COMPENSATION DECLARATION F1XTI3RES PER TRAP SCHOOL TAX Y N
c Edi hereby affirm that I have o mrtficstsuranc of oneacamnt to pytheatre,mof or RECEIPT a
601(Iab of Worken'Campensatlanlnsuranceaa certified copytheieo(ISec. GAS EA.SYSTEM-1 INCAOUTLETS PARKFER Y N
3BOq abC
Policy,
RECEn>r« ,.
Cn;aSYSTEM-OVER 0(EA). BUILDING DIVISION FEES
Cam any 1 � _ -
nified copy is hereby famishedGAS EA.. GREASE/INDUSRL WASTE INTERCEPTOR PLANCI-IECKFEE
Certified ropy la(Bed with the city Wpedion divlalon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP.NSAPAID ,
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200F7. Date Remi t#
(Thiamctionneed ndbeNSA lithe permit lafor one hundred Bolla.
(SlOa)or less.) WATER HEATER w/VENT/ELTCTR ENERGYFEE Y N '
I certify that In the perforrrunes of the work for which this permit is Issued,
I shall not employ any person in any manner w as to become subject to the WATER SYSTEM/TREATING -
Workers'Compensation laws of California.Date PAID
'ZZ Applicant NrgW RESIDENTIAL PLMB. SQFT. Date ItCCCI t#
O NOTICETO APPLICANT.If,after making thIsCerlifiateof Exemption,you
should become subjectto the Workeri Compensation provisions of the Labor TOTAL:
W Code,you moat forthwith comply withsuch pro,bilons or this permit shall be
WY deemed revoked. .• B •BUILDING FE
a - CONSTRUCTION LENDING AGENCY , SEISMIC FEE
I hcmbyafRrm that there 0 a construdlon lending agency for the perform ELECTRIC FEE
Z ante of the work for which this permit la Issued(Ser.3097,Civ.C.) TOTAL:
U',O Lender'.NamePLUMBING FEE
LL I- Lenders Address 4T' MECHANICAL PERMIT'„ "JTM" MECHANICAL FE•E -
OW I crAllythat l have read thb.ppliathm.cel state thatlheaWve lnfomn en
CL IsmrrM.I agree to comply with allcity and muntyerdleances and pate laws PERMIT ISSUANCE FEE$PND:
>. relatingtobullding commutl°n,and hereby authorize representatives ofthis
H W city to enter upon the above-mentioned property for inspection purposes. ALTIEORADDTOMECH.
Z (We)agree to save,indemnify an d keep harmless the City of Cupertino Date RecdPt#
V against llabilltles,judgments,coa...d expenses which may In any way accrue AIR HANDLING UNIT(FO 10,000 CrM) SUBTOTAL'
Id City In con a o! gra tl gof thl permit
a ARHANDL NG UNIT(OVQt 10,pO CFM) CONSTRUCTION TAX
I no reof Appllant/Contractor - Date. IXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUSMATRWRLSDISCLOS9
Will the applicant or future building occupantatore or handle hazardous HEATINGUMTI70100,0DOBTU) Date Reuel t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the - -
r H❑ Yand SafrtyCWe,Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) - TOTAL:
Will the applicant or❑future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) - ISSUANCE I DNCE DATE
which emit hazardous air contaminants as defined by the Bay Area Alr -
Quality Management District? BOER-COMP(3tB'OR 100,OfpU) M-
BT
P
Yes Nu
Ihavimadthehazar1earraterialsrequirements underChapter6.95of BOILER-COMP(OVER 100,000 TIM _
the C.Efcmi.Health&Safety Code,Sections 25505,2SS33 and 25530.1 - MAR .'199
O
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.Ff. 1 s7
responsibility to notify the ocmpant of the requirements which at be mel
'PrloF to issuance of a Certificate of Om pa nry. iCIIY Vt- Duren fir r
r r
Owner or authorized agent Data - - ISSUED BY
TOTAL:
OFFICE COPY