23934 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
'
Building Project Identification -PERMIT NO.
Building Address: 23934
i a 8 � GF) ciSO i
�yneroL ante: none:n p p
YQt.IRGC� �0.I�PIYYIP4.$P/ �o-O II CITY OF CUPERTINO-BUILDING DIVISION
Contntor'a Name: Lic.No: APPLICATION / PERMIT -7,
• Architect/En oe r: BLRLDING-ELECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL '
g e Lie No:
QTY ELECTRIC PERMIT FEE - BUILDING PERMIT INFO
Address•. PEMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter9(cemmem, APPLIANCES-RESIDENTTAL OBD
ingwith Section 7000)of DiWsion3oflhe Businemand Professions Code,and my '1
license[sin full force and diet. PANELSv'
License Claes LIc.N
Dale LIET0200ANTS '
ARCHITECTS DECLARATION 201-1000 AMPS
Z I understand my plans shall be used as pubbe records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.Ff.
CO
d(2 Licensed Professional SIGNS ELECTRICAL ._ _..,.,y,•,
z
6 w OWNER-BUILDER DECLARATION
'I,'i a Fn SP[CIALCUiCUIT/MLSC
HA Z Ihereby affirm that[ant exemptfrom the Contractors License Law for the '
'Z O A following reason.(Section 70315,Business and Professions Code:Any city or D. N
O Z t-� TENP.METER OR POLE INST.
Cucountywhich requires a permit tocenstrut,alter,improve,demolish,ormpair,5—" anystmcture priorto its Issuance,also requlrestheappliant forsuch permit to POWER DEVICFS
�+ V file a signed statement that he N licensed pursuant to the provisions of the
3a Contratnrs License Law(Chapter9(mmmencing with Section 700()of Divi- SWBdMING POOL ELECTRIC
O z sion3 ofthe Business and ProfesslonsCode)orthat he u exam therefromand VALUATION
the basis for the alleged exemption. Any violation of Settle.7031.5 by any OUILETSSWI.ICHFSFTXTURFS DATE 0/y 99 p
applicant fora permit subjects the applicant to a civil penalty of not more than
o five hundred dollars($500). NEW RESIDENTIAL E9nFT4YIR" — -
❑I,as owner oftine W 1 with wages as their sok 1—sQ'Fr: DMFS TYPE CONSTRUCTION
property,or my employees wi g
compensation,wfliciothe Business and k.and thest ode:Th not Intended or offered for
D sale(Sec.7044,Business and Profession Code:The Contntots License law
j $ does not apply to an owner of property who Wilds or improves thereon,and OCC.GROUP RFS.UNITS
who doessuchwork himself orthrough hisownemployen,provided that such
improvements are not Intended oroffered forsale.If,however,the building or T
improvement tsold within oneyearofcompletiogtheowner-builderwill have
rdcn of proving that he did not build or Improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE EPN
owner of the property,Sm exclusively contracting with licensed PERMIT ISSUANCE
cont,tors to construct the projet(Sec.7094,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VEM-WATER(EA)
Wilds or improves thereon, and who contracts for such projects with a .FEE SUMMARY
m,➢_t[ator(s)Brenxd pursuant to the Contntais License Law. BACK FLOW PROTECT.DEVICE
_ LJ 1 am exempt under See 'B k P C for this reawn
DRAINS FLOOR ROOF,AREA,COND.
SANITARY Y_ N_
Owner Date RECEIPT N
WORKMAN COMPENSATION
DECLARATION p RLS ppg.I.RAI' SCHOOL TAX Y_ N_
❑1 hereby a(firtn that I have a certificate of consent to self-insure,ora RE MPT N
certifiateofWmkenCompensation]nsurance or.certifiedcopy therm(Sec. CAS EA.SYSTEM-11NG40UTLEIS PARK FEE Y N
3800,Lab C.) RFLFIPI'N
Paltry N GAS FA.SYSTEM-OVER 4(EA)
Com any BUILDING DIVISION FEES
❑PCcniBed ropy Le hereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy V filed with the city inspection division.
CERTIFICATE OF EXEM PFION FROM WOR KERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANTTAI2Y-SIOR.M EA.200F7. Date Recfipt#
(This section need net W completed lithe permit Ls for one hundred dollars
($1(0)oWATER HEATER W/VENT/ELFCTR ENERGYFEE Y N
I certifyify that In the performanre ofthe work forwmi
hich this pert is Lssued,
I shall not employ any person In any manner so as to become subject to the WATIN SYSTEM/TREATING >
Worken'Compewtioniawsof Califomia.Date - PAID
0 Z Applicant FLEW RESIDENTIAL PLMB. SQ.FT. Date RCCeI 1#
Z NOTICETO APPLICANT:If,after making this Certificate Of Exemption,you
should become subject to the Workers'Compensation provisions ofthe Labor TOTAL:
� ; Code,you most forthwith comply with such provisions,or this permit shall be BUILDING FEE
W _ deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE _
a. O Ihereby affi rmNet there ba mratrutlon lending agency for the perform TOTAL: ELECTRIC FEE
:) Z anm ofthe work for which this permit is ensued(Sec.3097,Civ.CJ
02 IenderaName PLUMBING FEE
H Lender's Address Cry. MECHANICAL PERMIT FEE
O W Icertifythat l have read thisappliationand a tatethattheabove information MECHANICAL FEE
Ill. Lsmrrat]agree to comply with all cityand county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. relating to building construction,and hereby authorize,representatives of this
F N tty to enter upon the abovcmentio M property for Inspection purposes. JALTERORADDTOMECH.
2 (Na)agree to save,indemnify an d keep harmless the City of Cu pertinc, Date Receipt#
L) against ilabilltin,Judgmenta,costs and expenses which may in anyway accrue AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL:
Rai said City in rons q e re of the granting of this permit.
a ( _ry ASL � 7��I�� MR HANDLING u1.Tr(ovlxla000cl�l) CONSTRUCTION TAX
Signature ofRpp'ltc�am/ ter D-T'— aFuusrxooD(w/DUcn CONSTRUCTION TAX PAID:
Han//CM USMATERIA DISCLOSURE
Will the applicant orfuture building otvpant store or handle hazardous I'IEATING UNIT(TO IM,000 BTU) RCCfI f#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the —' —
Iicalth and Safcty Coal r Section 25532(e,)7 HEATING UNIT(OVER 1,1 OW BTU) TO••
❑Yes ri No
Will the applicant or futum building o pant use equipment or devices VENTILATION FAN SINGLE RESID) ISSUANCE DATE
which emit hazardous air mntamleants as defined by the Bay Area Air
• Quality Maosgcmcnt District? BOILER-COMP DHP OR 10,000 BTU)
Yes No
have read the hard ous materials requirements under Chapter 6.95 of BOILER-COMP(OVERI(0,000 BTU)
the California Health h Safety Code,Sections 25505,25533 and 25534. 1
understand that lithe building does not currently have a tenant,that It k my NEW RESIDENTIAL MECH. SQ.FT PAID A
responsibility to notify the occupant of the requirements which must Wre
, t f I D
prior to Issuance of a Certificate of Oa panty.
9.
Owner or authorized agent Date TOTAL: ISSUED Bi:
vurrnufv
OFFICE COPY v