23694 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project identification PERMITNO.
Building Address: 23694
ZT
D L/N 2 /ZD vrf.e?7�I.o ----M'U=N SUBMITTAL DATE
our. sine. CITY OF CUPERTINO-BUILDING DIVISION
Contndor's Name: Lie. re APPLICATION / PERMIT
BIIILDINGELECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL
A imet/Enfimen Llc.No:
QTY ELECTRICPERMFr FEE BUILDING PERMIT INFO
Address: I PERMITISSUANCE N F-1 ❑
LICENSED CONTRACfOrpr DECLARATION
I hereby edion7 thallaiv M=3ofhe under BuslrovWonaoffendoer9(rommne APPLIANCESRESIDENML JOB DESCRIPTION
lngwltliumseh I.full
(theBumnneandProfnmonsCode,and my --t V - '
license Is In fuB farce and ic.0 PANELS LANTS `'
DateLimClam LIcM O
Date. C.ntndor
ARCHITECTS DECLARATION 701-IOCOAMPS
ec Iunderstand OVERIODOAMPS - _ SQ.FT.FLOOR AREA $/SQ.Fr.
my plain shag be used n public records. nto
b Licensed Professional SIGNSELECTRICAL I .I n, �. D N
ISPECIAL CIRCT/MLSC
6 OWNER-BUILDER DECLARATION
n IR ` (d����ER
Ihe.byaffhmthatlamexemptfromthe Conlndoe.Li...U.forthe V
'72.0a ecurtingreaa n.quiecta permittoousinemand Pimprove,Code:Anympaicity r TEMP.MUIRORIOLE IN ST.
F`�i' rountywhich requireaa permit to mtutruR,alter,improve,demollah,arrepalr
any stmdu m prior to ih Issua me,a lm requires t he a ppRcant fo such peemit to
file a signed statement that he is licensed pursuant to the provisions of the POWER DEVICES tC DAT —�� JI
3w� Contractor's Lice .La-IChapmr9(cem
mencleg with Section MM).(Divi- t SWIMMING POOL ELECTRIC ��
SOS mon3ofthe Brafem
uslnessand PlomCode)orthathe Isemmptthem(mmand VALUATION
5 the basis for the alleged exemption. Any violation of Section 70115 by any OIITLETSSWITCHESHXTURES
applicant fora permit aubjMs the applicant to a civil penalty of nut more than
five hundred dollars%WL
I,as owner of the pro", NEW RESIDENTIAL ELECTRSQ.FT. STORIES TYPE CONSTRUCTION
p orka or my is
r their
sam(Sec.70Ktion,ll..will Botheworkandthested.: h notintendedorm.Loffered for
O sale(Sec.70K to ahem and fpropePd.property
Co Wilds C improves Licenae Law '
does net applytoan owner ofproperty who norImprovesthereon,and OCC.GROUP RFS.UNITS
who Improvements am
khimseEorlhwghed own employees,p ,theb that such
Improvementsarenotintended orrofco (plebe.If,h er.g deer ilingve
Improvementbwldwithlnomyrarofcompldbgtheowner-bullderwlllhave -,
01Lurden of proving that he did not build or Improve for purpose of sale). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
1,-J L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
cont'-don,to cerutruct the projod(Sec.7044,Business and Professions Code:
The Cmdr cte.License Law does na apply to an owner of property who ALTER-DRAIN&VENT WATER(EA)
builds or Improves thereon, and who contracts for such pcojed •
s with a
c.6
FEE SUMMARY
o��BBllactor(.)licensed pursuant to the Contrad.e.Limn.Law. BACK FLOW PROTECT.DEVICE
I am exempt under Sec B&P C for this reason
OUTSIDFFEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Data RECEIPT#
WORKMAN COMPENSATION DECLARATION
E31pD(•p(Tgpg PER TRAP SCHOOL TAX Y_ N_
I hereby affirm that I have a metlficate of consent to self-Insure,or RECEIPT Y
cenlficate of Workees'Compewtlonlmunnce.racertllled ropythereo((Sec. GAS EA.SYSTEM-1 INC4 OUTLETS PARK FEE Y N
3#00,lab C) RECEPT 0
Co11ry Y GAS.EA.ESYSTEM-OVER 4(
VER (PA)Cany gU1LDING DI VISION FF.GS
�7 ffCertiOed copy is hereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy Is filed with the city i.pedl.n division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 700F7 Date Recei t#
(Thisare ion need net M completed R the permit Is Toro.hundred dollars
(S100)orlcss.) WATER HEATER w/vENT/Q,ECTR ENERGY FEE Y N
I certify that In the performanexaf the wok forwhich this permit le Issued,
I shall not employ any person N any manner n as to become subject to the WATER SYSTEM/TREATING
Worker'Compensation Laws of California.Data
PAID
Z Q PP gQFr. Date Recei t#
NOTICETO APPLICANT:IL after making thisCertRlcate of Exemption,you NEW RESIDENTIAL PLMB.
should become subject to the Workers''Compematlon provisions ofthe Labor . TOTAL:,
y
Code,you=a,forthwith comply with such provisions orthls permit hall be U IN
W
> decreed revoked.
G FEE
CL G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hembyafRemthat there Isaccommetion lendingagency forthe perform, TOTAL: ELECTRIC FEE
Z aIINO
rm ofthe work forwhlchthb permit Is lssued(Sm.3097,Civ.C.)
(� O Lender.Name PLUMBING FEE
ly H Lender'.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW isceallI cadlfythatt have read theapplicatl.nand statethat theabovelnformatlon
1 rmet.I agreeto coreplywith acity and county ordinances and mate laws PFRMITISSUANCE FEES PAID:
>- W relzengtobulUd gmmtmdim aMh mbyautho mpre.ntativnofthIs
U t entero n the above�rmntlomd f inspection ALTERORADDTOMECH.
~ ? ty(We)agree m save,Indemnify an d keep hamdem the lty of Cupedino Date Recei [#
V against lbblWies,judgment,cestsand expenses which may in anywayaccem AIR HANDLING UNIT(TO 10,OD0 CFM) SUBTOTAL:
agairince of PIPWArting of thisq/i
77 AIR HANDWNCI UNIT(OVER IO,mOCFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant mom or handle hazardous HEATING UNIT CED 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety Code Section 25537(a)7 HEATING UNIT(OVER 100,000 BTU) IOTA .
❑Yea No
Will the applicant or lure building occupant use equipment or devices VEN-ILATIDN FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air cenumdoarts as defined by the Bay Area Air
Quality Management District? BOILER-COMP DHPOR 100,000 HM P A O 0
4Yre cath.
hY',a the hazarQoue materials requirements under Chapter 6.95 of BOE ER-COMP LAVER 100,000 BTU) nn
the California Health&Safety Code,Sections 75505,75533 and 25534..I .•1�\/� O
understand that lithe building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQn. swiss/ i7 19
responsibility to notify the occupant of the requirements which must be met ����V/
pdortoL uanceofaCedlficateof Occupancy. C'il+
r CUr fy
Owner m authadmd agent Date TOTAL: ISSUED BY:
OFFICE COPY