23968 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address:' - 2 3 9 6 8
jb/q 1,4P4A A
tura ame: AAA 11
tl7lErtIS�� r #Jq � CITY OF CUPERTINO-BUILDING DIVISION M
c ,�mNr�'s�Name: ,,^ _ w APPLICATION / PERMIT
-D " 'U'J� � s^/ BUILDING¢ECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL N
AmhltenN cyr: Lie.No:
QlY ELECTRIC PERMIT FEE BUILDING PERMITANFO
AddmFs. l` Q 7Q PFRMITISSUANCE ��'• �rn[ �
LICENSED CONTRACTOR'S DECLARATION c¢
IherebyafrlrmthetlamBcensedunderinessa dPreChapter9(commenc- APPLIANCES-RESIDENTIAL F3fk'tt�g�G -
IngIherebction70thatI iWslon3ed un erprova!nd's cf Chiomr 9(comdmy
limn.I,In full fo++qq and effect. V& PANELS
Limn CIav12LIc.N 'AW t�3
Date -1(L Contractor /j_, —UP TO 290 AMPS
ARCHITEC'S DECD RATION 201-1000 AMPS
W (understand myplarushallbeused aspublicrecords. OVER1000AMPS R S/SQ.Fi.
G❑ g
E U Licensed Professional SIGNSELECTRICAL v
OWNER-BUILDER DECLARATION
b`r a sof SPECIAL CIRCUIT/M1SC I lam,
I" }_ (hereby affirm that I exempt ER DE LARATIO Llrenx Law for the
G P�pp following reason.lSection 7031.5,Business and Professions Code:Any city or TEMP.METER OR POLE(NST.
DA E
/Q
O!. W rountywhichmquresapermittocomtmdalter,impmve,demolish,orrepalr
❑ v anystructure prlorto its lsauance,also requiresthe applicant forauch permit to POWER DEVICES
O 0 U file a signed statement that he is licensed pursuant to the provisions of the
O e Contractor's Lice.Law(Chapter 9(commencing with Section 7000).f Divi- SWMMIN'G POOL ELECTRIC
O< sion3ofthe Businevand Professions Code)orthat heisexempttherefromand VALUATION
,fE$^B p Ot the basis for the alleged exemption. Any violation of Section 7031.5 by anyOUTLETSSWITCHES-FT%TLRES 1 2 O a'•V�.
applicant for a permit subjects the applicant to a civil penalty of not more than
five hundred dollars($SOO).
m NEW RESIDENTIAL ELECTR Rf.
❑I,as owner ll the property,or my employees with wages r there sole c"U STORIES TYPECONSTRUCTION
71< compensation,Business and rofe ihes Code:Th aceIntendedorofferedLaw
w -
O sale(Sec.apply
to Business and f property
Code:The or imp c,the..e Ia d
S$ does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP RES.UNITS
who doee
ssuch work himself orthrough hisown employe ,provided that such
improvements arenot intendedoroffered forxle.lf,however,thebullding or T
improvement Issold within one yearof completion,the owner-budderwill have
th .,d co of proving that he did not build or improve for purpose of sale.). QTY. PLUMBINGPERMIT FEE FLOOD ZONE APN
Li L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business aed Professlom Code:
The Contractors License Law does not apply to an owner of property who ALTER-DRAW k VENT-WATER(EA)
builds or Improves thereon,and who contracts for such plojem with a
co,ttBl!fTanor(s)licen.dpunuanttothe Contractors License Law. FEE SUMMARY
L5 I am exempt under Sec. B k P C for this reason BACK FLOW PROTECT.DEVICE., OUTSIDE 17EESv
DRAINS FLOOR,ROOF,AREA,GOND. SANITARY Y N
l Owner Drte RECEIPT'N
WORK MAN COMPENSATION DECLARATION FIXTURES.PER TRA(' SGi00L 7A% Y N
� ❑1 hereby affirm that 1 have a certificate of conxnt to self-Insure,ora _- RECEIPT N
certificate ofWorksrd Compematlon lnsu rance oracerifird copy thereof(Sec GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE ' Y N
3500.Lab C.) RECEIPT N
policy N GAS EA.SYS(OVER d(EA)
Com any BUILDING DIVISION FEES
Certified copy In hereby furnished. GRCASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
❑Certified copy is filed with the city Inspection divlalon.
CERTIFICATE OF E)EMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA.2WF7. Date Recei t#
(This.nion need not be completed If the permit is forom hundred dollars
(51W)orless.) WATER HEATER W/VEM/¢ECTR ENERGY FEE Y_ N_
I certifythat In the performance or the work for which this permit is Issued,
I shall not employ y person in any manner so a9 grb' t the WATER
SYS.IEM/.I.REA.I7NC PAID
Workers'20 Hon U o B la. D e T
O Z Applicant NEW RESIDENTIAL PLMB. SQRT. Date Recei t#
Z O NOTICE TO C If,after making this Certificate of Exemption,you
should became orb' Chu Workers'Compensation provisions of the Labor TOTAL'
CC N Code,you most forthwith comply with such provisions or this permit shall bc BUILDING
W ] deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a.� Iherebyaf(Iron that there V acomtmctlon lending agency for the perform ELECTRIC FEE
Z ance of the work for which this permit V lawn I See 3097,Civ.C.)
O O lender's Name PLUMBING FEE r
LL Icnder'a Add.. QTY.j MECHANICAL PERMIT FEE
W
Icemlfythat l have read this application and statethat theabove Information MECHANICAL FEE
O .
1 is correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEESPAID:
>_ 0. to building construction,and hereby authodu representatives ofthis
N. city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
Z (We)agree to save,indemnify and keep harmless the City of Cupedlno Dale Receipt#
V against liabilArs,judgments,costsand expenses which may In anywayamme AIRHANDLINGUN1T(TOI0,W0CFM) SUBTOTAL:
r against idUlty Inco nce ee gr nypg of this pennon.
AIR HANDLINGUNIT(OVER 10,0011CFN) CONSTRUCTION TAX
signs, ofA licant/Contractor Date ExllnvsT HooD(w/Duch CONSTRUCTION TAX PAID:
e
HAZARDOUS MATERIALS DISCLOSURE
ja 'Ilthea licant or future building occupant store or handle hazardous HEATING UNIT CFO 10g0008TU
PP R Pa^ Ir Date Rccei t#
marem,as defined by the Cupertino Municipal Coda Chapter 9.12 and the
ikahh and Safety Code Seniors 75532(x)7 HEATING UNIT(OVER Iffl,0 B'TU) TOTAL:
❑Yes MN.
Will the a pplicaut or forum building oocapant use equipment or devices VFNTILATIONFAN(S LE RFSID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air A t V
Quality Mamgemrnt DisMNo BOILER-COMPP OR 100.IXD BTID
4Yes ❑❑No
haveread Health
materials Sections 25505, under Chapter
of BOILER-CO. (OVLR100,000BN) 'JUL 1
the California atIft A Safety Code,Sections 75505,have
t and 25534.I 1.
4 qq2
understand that lithe building does not cv rrently have atenanL that ii6my N'LWR DEN37AL MECH. SQ.I7
�a to Issuance to onotify the
occupant
a c ant of the requirements which most be coed V UYCL I IIYt
pm• panty. '(�C)Ci�a�syr Ur "�
Owner or authorized agent Data ISSUED 171D —1iNs
TOTAL:
OFFICE COPY