23366 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification �j � PERMIT NO. -
Building re — 1E 23366
endersName-
A
g �Yr-j2y0-n.l CITY OFCUPERTINO-BUILDING DIVISION
t. c°^ a°r°"•de,�{ Lk'"°� APPLICATION /PERMIT 3
Wa SChl-N.iv�r�/' 36 1s;! BUILDINGELFCTRICALPLUMBING- F HANICAL CATEGORY CONTROL II
Architect/Engineer. Lk.No:
aNQTv ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address:PC &pZ Z� �thyG NC.A o PERMITISSUANCE �� ❑ ECKIR
1:1 ElLICENSED CONTRACTOR'S DECLARATION
I hereby aQtrm that l am licensed under provisions of Chapter9(commenc APPLIANCFSRESIDENEIIAL JOB DESCRIPTION
ingwith Section 70M)of DiW.lon3ofthe Busim..nd Profesrons Code,and my
Ilcense lsinfulHorcp�dti fes. 3632,3 PANELS ��..NP�. T
License Class``••%% .J Jb A JG.�/_ �/�y _
' Date Contractor f/T IIr�` r
ARCHITECTS DECLARATION 201-1000AMPS
reO O I understand my plans shall be used as public records. OVER IOOO AMPS SQ.FT.FLOOR AREA 5/SQ.FT.
)t Licensed Professional SIGNS ELECTRICAL
<< OWNER•BUILDER DECLARATION SPF-CIALCItCU1T/MLSC
t� �a ]hereby alNmlhallam exempt from the Contractors Ltcenr Law for the
qqqqqq following reason.(Section 7011.6,Businessand Pmfessklns Code:An city or
K ('� ceunlywhich requiresa permit to ronsmact,alter,improve,derrolbh,orrepalr 'D.l1P.MEITA OR POLE]NST.
anystmcture Inform its bsuanc,abe,requlrestheappllont forauch permit to POWER DEVICES
file a signed statement that he is Iirensed pursuant to the provblons of the
3µp-_ Contractors License Law(Chapter 9(commencing with Seaton 7000)of Divi. SWIMMING POOL ELECTRIC '
O.JJ37 elon3o(lhe Ruslnessand Pmfemlom Code)°rlhat he is exempt therefromand VALUATION
the balls for the alleged exemption. Any violation of Seaton 7011.5 by any ^T
<5 apph..t fora permltaubjecutheapplcanttoa civil penalty ofnot more t hon UTLETSSWITCHESHX'1'URES iV
five hundred dollars(45(10).
k z< ❑I,as owner of the property,or my employees with ended NEW RESIDENTIAL ELECTR as thele sole e"QtT' STORIES TYPE CONSIRIICHON'
compensation 4Z wW doth.work and Professions
b not Wended or coffered for
$a O sale(Sec Apply Business amifproperty Code;The or improves
mp noes License Law
w3B whodetapply loan owner of thdaug his o buildnem orim,provided
edthatherver,and
such
Occ.GROUP RES.UNITS
wA whodoesmAch mentsa not
Intended
ffered owns.If,hod,provided ilding or
Improvementsarenot Intended earofredfords.If,however, deer ill ha or T
Improvement iswld wilhinoneyvarafcomplMiostheowner-bullderwlllMave
t e Nen of proving that he dal not build or Improve for purpose o(ule.). QTy. PLUMBING PERMIT FEEFLOOD2DNE APN
Lj 1,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contraaom to construct the project(Sec.7044,Business and Professlord Code:
The Contractor's License Law does not apply to an owner of property who ALTER DRAIN&VENT-WATER(EA)
builds or Improves thereon,and who contracts for such PkD*&s with a
0)Banned pursuant to the Contractor's Llmnse Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sea B&P C for this rcaaon
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y NOUTSI �FEES
Owner Date RECEITp
WORKMAN COMPENSATION DECLARATION FIXTURES-PER TRAP SCHOOL TAX Y N
❑I hereby arthro that I have o certificate of consent d apytheu f(S . RECEIPT N
°enifiLab of Workera'Compensatlonlnsurana ora rertl(led copythereo((Sec. GAS B.A.SYSTEM-1 INC.l OUTLETS PARKFEE Y N
38m,Lab C.) e
GoliryY �/ CAS E.A.SYS EM.OVER 4(EA) RECEIefN
Com any BUILDING DIVISION FEES
�Cedified ropy hem r ish CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
�eal(led ropy b filed with the sty inspection division.
CERTIFICATE OF EX PFION FROM WORKER S' CREASETRAP PAID
COMPENSATION INSURANCE SEWII-SANITARYSIORM EA 200FT Date Revel t#
f[hbaealon need not becompleted tithe permit b foam hundred dollen
(4103)nify,th WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
]cent thatoIn the performanceofthunterawork so a to which
became
subjis based, —
I shall not employ any penton In any manner at u to berome subject to the WATER SYM Al/TREATING
Workers'Compematbn Laws of California.Dale PAID
Z Applicant NEW RESIDENTIAL PLMB._SQIT. Date Recei t#
Z O NOTICE TO APPLICANT:](,after making this Certificate of Exemption.
you
1" should hem.subject to the W°rken'Compa.t Ions provisions of the Labor TOTAL:
V3 Code,you=at forthwith comply with such provielons or this permit shall be
W > deemed revoked. G FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
UJ G
I hereby affirm that there is a construction lending agency for the perform ELECTRIC FEE
(Se
= Z an.of the work for which this permit is issued&c.3097,Civ.Q TOTAL:
as
02 Lander.Name PLUMBING FEE
LL.H Tendee.Adamd QTY. MECHANICAL PERMIT PEE MECHANICAL FEE W I artily that l have read this application ami rate that the above Information
1 bcorrect.l agree to comply with all city and county ordinances and rate lawn mmrr ISSUANCE FEES PAID:
>. to relating to building construalon,and herebyauthatlurcpresentativesafthb
F Z city to enter upon the above•msntioned property for Inspection Purposes. ALTERORADDTOMECH. Dale R0Ce1 t#
_ (WB)agree to save,Indemnify an d kcal,handler the City of Cu pen Inca
against liabilities jud me e,ronsand expend.which may In any wayaccme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL'
is dCl In a the granting of this permit. ALR HANDLING UNIT(OVER I0,000CFM) CONSTRUCTION TAX
a'Sigatiature of App t/co traci EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATER S SCLOSURE
Will the applicant or future building° p store or handle havardous I MATING UNIT(T0100,000 BTU)
material as defined by the Cupertino Municipal Cod,Chapter 9.1 Z and the _ Date Recef
go
I le❑alt Yaannd Safety Cod c,Section 2S532(a)i HEATING UNIT(OVER 100,000 BTU) TOTA
No
Will the xppliont or❑fumebullding occupant use equipment or d evices VENTI LATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havadous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP OHP OR 100,000 BTU) PAID
4 yes g No
have read the Maas ous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,00 BTU) NAR
the Callfomla Health&Safety Code,Sections 25505,25$33 and 25534.1 '1/IAe e�
undersl.ndthatlfthebuildingdonnotmrrentlyhaveatenanLthatitlsmy NEW RESIDENTIAL MECH. c-Rn 1 AR ?992
nespoatibillty,to notify the occupant of the requirements which moat be met /x
priorto LruanceofaCertificateof0cmpanry. C1I r Ur LUN
hit
Owner or authorised agent Date TOTAL: ISSUED BY:
OFFICE COPY