23410 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Add..: 23410
-2/6/7 .�.1 /� Cr,
on ame: Phone;
1 —s CITY OF CUPERTINOQBUILDING DIVISION 2
C ctoY.Name:® Lie.No APPLICATION /PERMITIre 7� Z
/t0 LSO BUILDING-ELECTRICALPLUMBING-MECF[AMGL CATEGORY CONTROL N
rchitect/Engineer. Lk.No:
QTY ELECFRICPERMIT BUILDING PERMIT INFO
Address: PFRn1ITIS5UANCE � ❑ ❑ ❑
LICENSED CONTR under pnovisionso(Chapterg
DECLARATION
the th Sb on7OOO)offflurnflult Di Bcensed 3ofthe usinmalonsof Chdons Co e,and m- APPLIANCE&RESIDENML JOB DESCR➢'iION
IngwehSeftdf7(IDO)of affeon3ofthe Bu/tl�neuand Profesdona Code,and mylicen
Lica. Is in full r . d ic,0 /.l PANdS
LI«rase Clam Lk:N
- Date 3—/ _J_ Contractor G
ARCHITECTS DECLARATION XII-I WO 15
q�v!)O I understand my plana shall be used as public records. OVER 1000 AM SQ,Fr.FLOOR AREA $/SQ.Fr.
k� Licensed Professlavl SIGNS ELECTRICAL A E
«<<' OWNERex NLDER DECLARATION $pECtpL CIl2CUfT/MLSC T E
I"' Iherebya(Brm that lamexempt ER DE LARActo/e Li«nee Law f«tM1e
oo followingrcason.(Sectlon7m1.5,Buemessand Professions Code:An cityr
FZb' county which«qulmaa permit mconstmct,alter,Improve,demolbh,orrealr TEMP.MEITR OR TOLE MS I
any structure prior to its hsuance,aborequirestheappllant forsuch permit to POWER DEVICES E 9
ilk a signed statemethat he b Ilccnudi pursuant to the pnwbUv of the
Ou, Contractor'sLicense Law(Chapter 9(mmmencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
VALUATION
SOS elon3ofthe Bushes,and Professlov Code)orthat hell exemptiherefromand
,.1 Z baste for the alleged exemption. Any violation of Section 7031.5 by any
GS
applicant fore permit subjects the applicant to a civil penalty otnat more than OIJ7LETS-SWITCHES-FTXFURFS
five hundred dollars(WO). SQ,Fr. STORIES TYPE CONSTRUCTION
�n ❑I,as owner at the property,or he employees of with wages r offered
wk
NEW RESIDENTIAL ELECTR
um is
C a mm(Sec.7044,wusdothe essand rtreand t."Cde:TheC ,dead or La.
5 q sae(Sec. ppy to Businessandpropety Code:The or improves
LI«vefad
(/,I B does whodotapply torn imserofprough who nemporimprovnlhereoRand OCC.GROUP RIS.UNITS
WW was doeeeuchwork himxl(orthrwgh his ownemployeea,provided that such
Improvemen0 are not Intended oroffemd fm ule.If,however,thebulldlog or TOTAL:
Improvementlasoldwithln oneyearo(complelWn,theowner-bullderwill have
t rdeo of proving that he did notbuidorimproveforpurpose,ofuk.). QTY, PLUMBING PERMIT FEE FLOOD TONE APN
Lj f as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to cons90,construct the project(Sec.70Business and Professions Code:
The Contractor's License Law does net apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves therem
on,and who mrecfi for such ptojects with a
cj5anor(a)licensed pursuant to the Connector's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B k P C for this reawn
OUT&I UP FEES
DRAINS-FLOOR ROOF,AREA,COND. SANITARY Y N
Owner ECLDat RECEIPT M
WORKMAN COMPINSATION DECLARATION FIXTURES PER TRAP SC}100LTAX Y _ N
❑I hereby or@m that I have o«rtificadeurinc of consent to op theendiname,ora RECENT N
3800,cerfifab of Workera'Compevatlanlvurance«a certified copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARKFM V N
Poli Lab CJ
Policy N RECENT M
CAS.EA.SYSTEM-OVER 4(EA)
ray BUILDING DI VISION FEES
ertlfled copy is hereby thfurnished.
�CertlRed copy a toed withh1M city inspection division. CREASE/INDUSTRL WA5TE INTERCEPTOR PLANCHECK FEE 71:1'69 t
CERTIFICATEOMPE EXEMPTION IN FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA ]OOFI. Date Recei t#
Rheneed rad be completed lithe permit Vforone hundred dollen
(5110).el..)
certify
that
m « WATER HEATER W/VENT/Fi FCTR ENERGY FEE Y N
I«rtllythat In the performance (arwhlch this permit blued, WATER
I shall not employ any person In any mi nner eo se to become subject to the WATER SYSTEM/TRFATIN'G
Workers'Compevatbn laws of GII(omk.Date PAID
Z Applicant NEW RESIDENTIAL PLMB, SQ.Fr. Date Recei t#
Z O NOTTCETO APPLICANT:](
after reakingthb Ceriltlate of Exemption,you
should become subJect to the Workers'Compevat Ion pnevklov of the Labor TOTAL:
cc N Code,you must forthwith comply with such provkbv or this permit shall be �e
W j d«med revoked. 6 [
CONSTRUCTION LENDING AGENCY
CL c SEISMIC FEE
I hereby a.,m that there V a mvtrunlon ending agency for the perform
7 O once of the work for which tM1e pormit Le blued(Sec.3097,CIv.CJ TOTAL: ELECTRIC FEE
O _ Landers No
PLUMBING FEE
LL F I.ender'e Addreea QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O WI«rtltythatlhavereadthbappllatlonanddatethattheabovelnrormtion
le cormct.lagree to complywlth ellntyand countyoMlnanmsand pate laws PERMIT ISSUANCE FEES PAID:
} G relating to buildin mvtrunlon,a hereby authorize reprexntativa of thio
F Z citytoenterupon cabove-men ned pmperty for Inspection purposes. ALTERORADDTOMECH.
(We) to nae,Inde andk«pharml.the City of Cu pert Ino Date Reel t#
V again. a 111tie, dgme Its sand expeneeswhichmaylnanywayacerue AIR HANDLING UMTCTO 10,ODO CFM) SUBTOTAL:
.gal dC 1 mnsegtl orthegramingofthis peredit.
.x 3 - Z AIR ANDL NG Mr OVER IO,000CFM) CONSTRUCTION TAX
SI ore of pBanl/ ant nor nate IXHAUS'f}100D(W/DIKT) CONSTRUCTION TAX PAID:
I D SMATERIALS DISCLOSURE
Wllltheapplia rat or fu building omapant store or handle hazardous HEATING UNIT(TO I(DWO BTU) Date RC[CI t
material as defined by the Cupertino Municipal Code,Chapter 9.I4,and the
ltrallh and Safety Cade Section 25537(x)7 HEATING UNIT(OVER 100,000 BTU) TOTA
❑Yea No
Wlllthe appliranlm turebuilding.pantuseequlpment ordevices VENTILATION FAN(SINGLE RFSID) ISf1rrSS�)UAApN(�`�T r"�ATE
whichemit hazardou.air contsminams..defined bythe Bay Arca Air BORER-COMP P A C N
Quality Management District? PEN OR 100,000 BTU)
4 Y.. he n No
haif.l.Health
Safety
m ode, ba Serequlrer505,25 erChapter 534. 15 of BORER-COMP(OVFR]OD,000 BTU) EVI�R 18 199E
the Glifomla}Ieahh&Safety Code,Sections 75533 and 25534. I
understand that if notify
the-cUpooa not the
e.tew which
that It met NEW RESIDENTIAL h1EC71. SQ.FT.
responsibility to unify the occupant of the requlrcmente which mwt be met
prior to ksu.n«ofa Cerifflate of Ocmp.nry. CIIY Ue CUrCn Iry
Owner or authodud agent Date ISSUED BY:
TOTAL:
OFFICE COPY