23825 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: �'Y f��'f^
/O;s (p LGOCA G � GIS/ l82
771wnere area: one. A A A .
eV IS— SS 2i CITY OF CUPERTINO-BUILDING DIVISION
^Coosnicactor•a Na me: U,Ncc APPLICATION / PERMIT
J.E2avell1v P L," BUILDINGELECTRICALPLUMBING-MEC}IAMCAL - CATTERY CONTROL p.
Archima/iingincre.. Lie.N.:
,Q ��/ ,a� QTY ELECTRIC PERMIT FEE - BUILDING PERMIT INFO
Address: o� 1 h+ 36Z SA'7� PFRMITISSUANCE BL� UECI IT= 7T
1-1 ❑ [ILICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under prervLsioMofChapter 9(mmmore APPLIANCES-RE31DEN77ALJOB DFSCRII'1lON
Ingwith Sedion7000)of Dlvlsim 3oftheBminessand ProfessionsCodgand my /
license is In full force rad effeet. n r1 Y y I PANE (/(
Ll.mk CtknC-3L LS
LieM 61 �, � /-
Date (off? -4, T ct
Contraor ""
UP TO 2DO ANTS P
ARCHITECT ECLA ATION 211-10DOAMM
N 2 I understand my plans shag be u w public records OVER 1000 AMPS SQ.Fr.FLOOR AREA $/SQ.Fr.
ZOF
V Licensed Professional SIGNSELECTRICAL
6 w OWNER-BUILDER DECLARATION
7 s, y Iherebyaffinn thatlam exemp[(romthe Contractors License law(piths SPFCIALCIRCUIT/MISC
following reason.(Section 7(01.5,Business and Professions Code:Any city or 'Tf +
C S,o county which requires a permit to mnstmct,alter,improve,demolish,orcepalr TEMP.METER OR POLE INST. - / 1 1
F� any structure prior to its Issuance,also requires the applicant for such permit to BJa
OU file a signed statement that he is licensed pursuant to the provisions of the TOWER DEVICES p
3 p CmtracMrs License Law(Chapter 9(mmmenc og with Sectlon 7000)of Divl- SWIMMING POOL ELECTRIC ry
sion3ofthe Business and Professions Cade)orthat he b exam therefromand - ON'
y.' the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS-SWITCHESHXTURES
�i applicant fora permit subjects theapplicant to a civil penalty of not more than
E o five hundred dollars(SW. NEW RESIDENTIAL ELECTR SQFr. S'MRIES TYPE CONSTRUCTION
F1 1,as owner of the property,or my employees with wages as their sok
. �7.¢ compensation,will do the work,andthestructure Lana intended or offered for
5 D sale(Sec.7064,Business and Professions Code:The Contractors License Law
�SQ does not apply to an owner of property,who builds or Improves theme,and OCC GROUP RLS IATIS
who does such work himself or through his own employees,provided that such
Improvements are not intended proffered for sale.11,however,thebuilding or TOTAL:
Improverneissold within oneyearofcompletlon,the owner-buflderwill have
tlig_�uMenofpmving that he did notbuildorlmproveforpurpoucofsals.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed pFRMFr ISSUANCE
contractors to constmct the project(Sec.7064,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN VENTWATER ffNN
Wilds or Improves thereon,and who contracts for such plujem - -with a FEE SUMMARY
contrado(s)Located pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
F-1I am exempt under Sec. B h P C for thisas
.reason,
DRAINS-FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEIPT N
KM
WORAN COMPENSATION DECLARATION - FIXTURFS PER TRAP SCHOOL TAX Y N_
reIJEhereby affirm that I have a certificate of consent m self-insure,or RECEIPT N
ceAifimteLabCfWorkers'Compematimlnsuranreoramdifledmpythereof(Sec. / GAS EA.SYSTEM-1 isicwu ns _ D PARK FEE Y NM00 _
RECMPT N
Policy N GAS EA.SYSTEM-OVER 4(EA)
am any BUILDING DIVISION FEES
C
❑PCertiied copy Is hereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
PUCertlfied copy b filed with the city Inspection division.'
l'Y CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER- STOW-STORM FA.XIOFr. - DatORCCei t#
(Thissectlon need not be completed If the permit bfor one hundred dollars
($10ftorless.) � ENERGYFEE Y_ N
Icortify that in the performance ofthe work forwhlch this permit is issued, WATMHFATFRW/VENT/ELECTR —
1 shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TRCATfNG
Workers'Compensation taws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQFf. Date Recei t#
Z O NOTICE TO APPLICANT.IL after making this Certificate of Exemption,you
Fshould bemire subject to the Workma Comperantim provisions of the Labor TOTAL:
Code,you must forthwith comply with such provbiom or this permit shall be
W > deemed revoked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a O Thereby affirm that there is a construction lending agency for the perforrry TOTAL: ELECTRIC FEE
Z anceofthe work for whichthls permit is issued(Sec.3097,Civ.C.)
V O ' I<.dcrb Nana .1�:v PLUMBING FEE
LL I— Lmdre.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
WIrertlfythat l have read this.pplicati ..r uistatetlamtheaboveinfomutim
4 iscorrect.IagreetocomplywlthaBtltyand county ordinanms and state laws PERMIT ISSUANCE FEES PAID:
>_ relatingtobuilding construction,and herebyauthorlocrepresentativesofthis
N city to enter upon the above-mentiomd propertyforbuprelim purposes. ALTFRORADDMMECH. -
Z (We)agree to save,Indemnify and keep harMess the sty of Cupertino Date Receipt#
V against liabilitan,udgrrents,mets and expenses which may In anyway same AIRHANDLINGUMf R010,(DO CFTi) SUBTOTAL:
against said City In consequencuEII pp�� I, ofthl.pennit
��� AIR HANDLING lIIs7T(OVER IO,WOCR.f) CONSTRUCTION TAX
Sig tuns of Applicant/Contractor V Dare EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WilltheappBant or future building occupant store or handle havrdous BEATING UNIT(TO IW,OOD BTU) Date RCCeI t#
material as defined by the Cupertino Municipal Cade,Chapter 933 and the
Healthand Safety Coder�-S�edion25532(a)? HEATING UNIT(OVFR 100,000 BTU) TOTAL: S�Ti
r7 Yea II No
Willtheappliwnt or future building occupant use equipment or devices VENTILATION FAN(SINGLE RISID) ISSUANCE DATE
which emit berurdous air mmamipants as defined by the Bay Area Air pp D
lity Management District? BOILER-COMP PFR'OR 100,000 BTU) P M
�a�J Yn No
(have read the ha Y materials requirements u oder Cha p(er 6.93 of BOILER-COMP(OVM 100,000 BN) t -
the California Health faSafety Code,Set Ions 25505.Z03 and 25536. 1 -MJUN 1 `Z 1992
understand that if the building does not ca meetly have a tenant,that it le my NEW RESIDEALMECH. SQ-Fr
responsibility to notify the occupant of the requirements which at be met
priorto LssuanceofaCediffcateofOmupancy. CII Y OF Lau,�an 1114U
Owner or authorired agent Date 70TAL: ISSUED BY:� �1ny_C(f .
OFFICE COPY