23503 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Protect identification 9 O r PERMIT NO.
,i*gVM: Cris to /2�- Y, ��2. e . 23593
Owner'. came: �oner�:
CITY OF CUPERTIN0.6UILDING DIVISION
C
mo w APPLICATION /PERMIT
' eo a BIALDINGELECTRICALPLUMBINGMWHAMCAL CATEGORY RY CON0
rchitect/Englraer. Lk.No:
��8- QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address J {'V re'. PERMITISSUANCE /'� ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirmthat l am licmand under provisions a(Chapter 9(comment, APPLIANCESRESIDENDAL OB DESCRBe110N
Ingwlth In ton7000)o(DlNmon3 afehe Bumnessand ProfeasloneCode,end my
license lain(uRand dfect —] PANEfS \J
License la Lic.N�ji r
Date Contactor
ARCHITECTS DEC RA ION 201-IODO AMPS
07O I understand my plans shall be used as public records. OVERIWDAMPS SQ.FT.FLOOR AREA S/SQ.FT.
Licensed Professional SIGNS ELECTRICAL
�6 OWNER-BUILDER DECLARATION SpECIALCEiCUIT/MLSC �jl ® \�
7p., thereby a(Rrn that l amezemptfromthe Contradoe.LicenaeLawforthe ... bop ...., VV
O q following....(Section 7W1.S,Bu.lnerand Professions Code:My city or
1"'iy countywhkh requlresa permit tomtutrun,alter,Improve,derrollah,orre air TEMP.MEfER ORPOLE]NST.. uf;.jl
P 7 my atmRoxi statement
Is
rcqu pursuant
provisions
of to A
li nla..igned statement that he(Chapter 9 erne pursuant it the pro 7000) of the �W�DEVICE' I V /'1
Contractors Business
License LawProfessions
(commencing with Section 7000)of Divi.
30:7 sbn3o(the Busher end ProferlomCode)orthat helaexempt lhercfromarW SLVN4h9NC IDOL ELECTRIC ON I
Q.•77 O JI
applicant fora permit subjectsthe applicant to a civil penalty of not room than
the basis for the alleged exemption. Any violation of Section 70113 by any OU[LETSSWITCHF5HKIURES
five hundred dollars($SM. NEW RESIDENTIAL ELECTR SQF7. STORIES TYPECONSIRUCTION
�n ❑T,as owner of the property,or my employees with wages as their sole
mmpcneatioq wRldothe wmk andtheslmmm b not intended or offered for
psale(Sec.7044,Business and Professions Code:The Contractor's License taw
3� does not apply to anowner of property who builds or improves thereon.and OCC.CROUP RES.UNITS
who docssuchwork Mmvelf car through hi.own employees,provided that such
Improvement.ere not Intended oroffered forule.IL however,thebullding or 7
improvement Iewldwthinoneyeamfcmnple Wmtheavner- HderwBlhave
Up.tfurden of proving that he did not baud or improve for purpose o(eale.). QTY, PLUMBING PERMIT FEE
LJ L as owner of the property,am exclusively contracting with licensed FLOOD ZONE APN
mntractons to construct the projM(Sec.7044,Bushes and Prf,.Wa Code: PERMIT ISSUANCE
The Contractor's License taw does net apply to an owner a property who
bonds or Improves,thereon, VENi-
thereon,and who contracts for such pwiecia with a WA MAI
oq➢((e ror(s)licensed pursuant to the Contractor's License Law. FEE SUMMARY
LJ I am exempt under See B&P C for this maven BACKFLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,CON). SANITARY Y N
Owner Date RECERrT N
WORKMANCOMPENSATIONDECLARATION FO('TIJRFS PER TRAP SQi00L TAX Y N
QI hereby affirm that I have a certlRcate of consent to selfdnsum,ora.� RECEIPT N
LbC)artRlorken'Comperallanlruranceora certified copythereof(Roc. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Policy N CJ
Pollep DINGRECEIPT N
Com any CAS EA,SYSTEMAVERd(EA) BUILDING DIVISION FEES
CertT mpyb hereby(urnl.hed. GREASE/1NDUSCRL WASTE INTERCEPTOR
PLANCHECKFEE
Certified ropy is filed with the city Inspection dlvlmon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCESEWQbSANITARY-STORM FA.2001r1'. Date Reuel t#
(Thle section need not becomplated B the permit h forone hundred dollars
($1000mler0 WATER HEATER W/VFN'T/m rt•,I.R ENERGY FEE Y N
I amlythat In the perfu anceofthe work forwhich this permit is hsued,
I shag ml employ any perwn In any manner w r to become wbjed to the WATER SYSTTM/TREATING
Workcw Compen.gi..Lawsof Califoala. Data
PAI])
0 Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Dale Recei IM
Z O NOTTCETOAPPLICANT:ILafter.kingthb Certiflateof Exemptlagyou
should become subject to the Workers''Compematlon provlalam a(the Labor TOTAL:
N Code,you=at forthwith comply with such provisions orthis permit shall be I LDING.
FEE
W > deemed revoked.
a c CONSTRUCTION LENDING AGENCY SEISMIC FEE 09
Iherzbyafnrm that'hem is a construction lending agency for the perform TOTAL: ELECTRIC FEE
D Z ancoofthe workfor which this permit is Issued(Sec.3097,Civ,C.)
U O Lander'.Name PLUMBING FEE
LL Landee.Addresa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertlfylhatlluvereadehis appliation and mate that the aboveinformmloo
C lamrect.I agreetoccmplywlth allcityand muntyordinancesand mate laws PERMITfSSUANCE FEES PAID:
} W relating to building comhuiIon,and hereby authorlas repmentatives of thio
F Z cltymenter upon the above-uemiomd property for inspection pu rposes. ALTER ORADDTO MECH. Date Recei [#
V — CIN.)agree to save,indemnify an d krep harmier the City of Cu Fortino
agahutlbbWtk.,prdgnxwb,cowx.cI..penses which mayi..cyw.y..a AIR HANDLING UNIT TIO 10,000 CFM) SUBTOTAL:
against said City in consequence of the gaming of this permit. '
AIR HANDLING UNIT(OVER I0,000CFM) CONSTRUCTION TAX
Signature of AppBant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant store or handle haeardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.IZ,and the
Hc.Ith and SafetyCedSec}Ion 73532(a)1 HEATING UNIT(OVER IDD,000 BTU) TOTA
MY. o
Will the applicant or tyre building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit harardous air contaminants as defined by the Bay Area Air � '
Quality Management DbMct BOILER-COMP DEEP OR 100,000 BTU)
4Ye. LL-- o
have read me harardoue matemala requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)� APR 9)the California Health&Safety Code,Sections 25505,25S33 and 25534.1 1992
understand that lit buildingdoanMmmntlyhaveatenant,thatitbmy NEWRFADEbMALMECH. SQFI �
raponsibllltylo the occupa oft Ire t which must be rM - CII Iy
Uf (Ch111YV
a dina
r sato to O n
nor authorized agent Date ISSUEDBY:
TOTAL:
OFFICE COPY