23563 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERNUTNO.
Building Address:
H 23563
Ea _ sonar ansa: one: - A A A
�TjYEN `�9GIcJAiV 9a7o3g6 CITY OF CUPERTINO-BUILDINGDIVISION , e
° C anor'sName: Lie.No: APPLICATION / PERMIT
BUILDINGELECTRICAL-PLUMBINC-MECHAMCAL CATEGORY' COMROL N
la Architect/Engineer. le.N. -
/' Q QTY ELECTRICPERMIT FEE -BUILDING PERMIT INFO
Address*6a/rot a'i .1 �7���0 PERhRTI55l1ANCE
LICENSED CONTRACTOR'S DECLARATION L� El �A- D El
I hereby affirm that l am licensed under provisions of Chapter 9(commone. APPLIANCESRESOENTIAL JOB DESCRIPTION
ingwlth SecHOn7000)of DiAsion3ofthe Businessand PmfeaslonsCods,and my a...
license Is In full fume and effe t. PANELS .dam J✓\Y/
License Clap G Lic.NS�4,9 l I
Date Contactor C IS: UP TO 2DO AMPS L
ARCHITECTS DECLARATION 201-1000 AMPS
XZ ' I understand my plans ahaB be used as public records. OVER 1000 AMPS 'SQ.IT.FLOOR AREA $/5Q.FT.
MO
Licensed Pmfessiawl ISIGNSELECTRICAL
Q w OWNER-BUILDER DECLARATION ' '
oj I hereby affirm thatlam exempt from the Contractor's License Law for the SPECIALCItCU[T/MLSC .
OZ followingremon.&dion7031.5,Buaineseand Professions Code:Anyatyor TEMP METER OR POLE INST. —" MPP
g'^Y T
countywhichrcluiresa permBtocowtruct,alter,improve,demolish,orespair IY.IV/� ICS+ I
anystrucurre priortoiblssuance,also requlrestheapplla'nt forsuch permit to (OWER DEVICES
4LC17 file a signed statement that he Is Brense l pursuant to the provbiore of the
3 O� Contractor's License law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
on 3 of the Businessand ProfessionsCols)°rthat heisexem therefromand
6 S nAT
the basis for the alleged exemption. Any violation of Section 7031.5 by any OU7LETSSWITCHESFIXTURES car'
applicant fora permit subjects the applicant to a civil penalty of not more than
five hundred dollar($500).
1 as owner of the ro NEW RESIDENTIAL ELECTR SQFI. STORIES TYPECONSIRUCTION
�n ❑ , P party,or my employees with wages r thele sok
compensation,will do the work and theatructure B not Intended or offered for
dile(Sec.7044,
apply
to a new and Professions Code:The C improvts license Law
does$ whodotapplytork owner ofproperty
rough who Wilds mpoyees,povidexs that
ssuchuchOCG GROUP RES.UNITS
who mucintended
sahimse dedoroughed owns.If,however,the dlhat gor
improverrents wnainlendedoroofcre pldio t ner- Hderwill gve T
improvement iswld withinoneyearofcompletion,theowner-W Bderwill have
th�urden of proving that he did nmbu0dortrnproveforpurposeofsale.). QTY. PLUMBING PERMIT FEE
J FLOOD ZONE APN
L
I,as owner of the property,am exclusively contractingndPo with licensed ppRMIT ISSUANCE
contractor to construct the project(Sec.apply
Business and Professions Code:
ThsWilds
or imofs License Law don not apply tct an owner of property who ALTER-DRAIN k VENT-WATER(EA)
Wads tr Improves thereon, and who contracts for sed, ptojects with a FEE SUMMARY
cortrctorexemt under Sm totheContractmn'e Llcenx Law. BACK FLOW PROTECT.DEVICE
❑I am exempt under Sec B h P C for this reason
OUTSIDE FEES
DRAINS A,FLOOR ROOF,ARECOND. SANITARY Y N
Owner Date -
RECEIPT If
WORKMAN COMPENSATION DECLARATION FIXTURES—PER TRAP SCHOOLTAX Y N_
❑1 he affirm that I have a certi0ate of consent to self-Insure,or a RECEIPT M
certificateofWmIeca ComperuaBen ImIa San.or a certified copy the.(cgee. GAS FA.SYSIM-1 INCA OUTLETS PARK FEE Y N
3800,Lab C.) RECEIT N
Policy# GA EA.SYSTEN!3OVER 4(EA)
Cam any BUILDING DIVISION PEES
CcmOed copy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANC14ECK FEE -
nCertified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.2(X)FT. Date RcC i t#
(This section need not be completed If the permit is for one hundred dollar _
($100)or WATERHEATERW/VENT/ELECTR ENERGYFEE Y N
[certify that m the performance of the work forwhlch this permit is rowed,
1 shall not employ any person in any manner so as to bec7fixe 1,1Z to the WATQt SYSIEh{/TREAITNG
Workers'Co^��^Deeggss��t'o�n laws of CaB( Date ti PAID
O A licant �i'�e'�d~ M Date Remi t#
Z2 Pp you NEW RESIDENTIAL PLMB. SQFI.
NOTICEcome subject
tothe, orkem'fter kompertattondnil this lateof Exemption,reano
should became subject to the Worker'Comperratlon provlel°ns of the Labor TOTAL:
N Code,you most forthwith comply with such provisions or this permit shall be BUILDING
seemed revoked.
FEE
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
(L ° Ihembyeffirm that there is a construction lending agency for the perform- TOTAL: ELECTRIC FEE
Z arm of the work for which this permit is issued(Sec.3097,Civ.C.)
(,) O Lender's Name PLUMBING FEE
LL N Lender's Address QTY. 'MECHANICAL PERMIT FEE
O w Iartilymatl have read this application and statethattheabove Information MECHANICAL FEE
erect.I agreeto comply with all city and county'ordinances and state laws PFRMITISSUANCE FEES PAID: '
} N relatlngtobullding com ucti°gand herebyauthoriu exprexnnativesof this
F Z
atyto enterupon the above.mentioned property for inspection purposes. ALTERORADDTOMECH. Date Receipt#
(We)agree to ave,Indemnify an d keep harmless the City of Cupertino
V against liabilitRkjudgmeru,mau.rad expenseawhich may in anywayaccrue AIR HANDLING UNIT(TO 10,"CFM) SUBTOTAL:
ag.i.r.saidrPly in consequence of the granting of this Permit.
�, 92 'AIR HANDLING UNR(OVER 10,000 CIM) CONSTRUCTION TAX
..— I
-_ -. Slgwture,of Appliesur/Cra,fraoS01 Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE '
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code,Seaton=W? HEATING UNIT(OVER 100,000 BTU)
TOTAL:
[—]Yea . °
Will the applicant or future building occupant use reulpment or devices VFNDLATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? _ BOILER-COMP QHPOR IDQ000 BTU) q
Yes NLN-
,?have
N
4havereadtheh 7rdousmaterials requlremntsunderChapter6.95of BOILER-COMP(OVER 100,000 BM H
the California Health&Safety Code,Sections 75505,25533 and 25537.1
understand that ifthe Wilding tloas not artently haveatenanq thnutVmy NEW RESIDENTIAL MECH. SQ.PT 23 1992
responsibility to notify the occupant of the requirements which most be cert APR �\
prior to Issuance o(a Ccrtlfiate o(Ompancy. 1( Nsas
tr�\�'1
Owner or authorved agent Dote ISgpgp BY.—
TOTAL:
OFFICE COPY