23267 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Pro'ed identification 7 PERMIT NO.
Building Address: ,0eL 3^23267 6 7
0 re me: one: G`AL G
WA /�� as'7-3�y CITY OF CUPERTINO-BUILDING DIVISION wry_ 7 q�
&A,N�-"� NN--LI=���.N ' APPLICATION /PERMIT C7
r `�'6a' BUILDING-ELF MCAL-PLUMBINGMF HAMCAL CATEGORY CONTROL N
AsMtect/Engines Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
naarea
PERMIT ISSl1ANCE F] 7-:17❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm 7OOD)o Divisi am 3ofthe er Busi o(Chapter9 h onsC(e,andm APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Innrac k i d1on7000)of d died.3OftheBmincaaand ProfesslonaCade,and my
license is In deffetl. PANELS
Limn V Lk.N
Date Gontnat0UP TO 200AMPS
AR shell ATION OVER00AMPS
00AM
q�+00q [understand my platy ahaB be used apubncrecoda OVER t000AMI'S
'c4 Ukv LicensedProfveL,rul SIGNSELECTRICAL affirm P U T E R
iii¢fA OWNER-BUILDER DECLARATION SPECIALCItCUIT/MISC �(/ /Q
p., Thereby arm thatIant exempt from the Contractor's License law for the ( 7
9 F.p following reason.(Section 7f1715,Business and Profrnbtu Code:Any city or Tp�P.METIR OR POLE!NST. ATE
z Z -
K< a =ntywhichrequirusapermittomnstmd,alter,Impmve,dem lish,ormpalr
K �a anystructure priorto Its Issuance,akorequlrestheapplicant for such permit to POWER DEVICES '+
O c.O file a signed statement that he k licensed pursuant to the provisions of the
3 t: Contractor's License law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING )OLELECTRIC slon 3 ofthe Business and Professions Code)orthat he is exempt therefrom and VALUATION
GE�jp1 yd the basis far the alleged exemption. Any violation of Se Ilan 70315 re any ���
aPPliamfor a permit subjects the applicant toativll penalty of not rtnretban OUTLGTSSW[TCHESFIXT[JRES
�G five hundred dollars($50(f). NEW RESIDENTIAL ELECTR
I,as owner of the SQ.Ff. STORIES TYPECONSFRUCTION
j^�n ❑ property,or my employees with wages as their sole
compensation,will do the work and the structure Iinot Intended or offered for
q sato(Sec.7066,Business and Professions Code:The Contractors License Law
5,$ does not apply to an owner of property who Wilds or Improves thereon,and
who does such work himself or through hisown employees,provided that such OCC.GROUI' ftk5.UNITS
improvements are rest Intended orefferd forsale.If,however,thebuilding or TOTAL:
i proven ntksoldwithinoneyearofcompl&ion,theowner-buBderwilltave
x rden of proving that he did not bunsale
ctd or improve for purpose of .). QTY, PLUMBING PERMIT FEE FLOOD ZAAPN
NE
�I,as owner of the property,am exclusively contracting with licensed pERMyp ISSUANCE
contractors to construct the project(Sec.7040 Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT WATER
(En)
Wilds re
ds or Impress thereon,and who contracts for such pWiects with a
c' t[+exerts)hcensed pursuanttothe Contractors License Law. BACK FLOW PROTECT.DEVICE
FEE SUMMARY
IJ I am exempt under Sec rea
B&P C for thin aon
• Owner OUTSIDE"I
Date DRAINS FLOOR ROOF,AREA,GOND, SANITARY RECEPTa
40RgNAN COMPENSATION DECLARATION
[� ereby affirm that I have a certl0ate of consent to elf-insure,or FIXTURES PER TRA' SCHOOLTAX Y_ N
cortifiate OlWorkers'Compensnum,Insurance or a nertilid copy them((Sec. RECEIPT N
3800,Lab C.) � �^ GAS EA.SYSTEM-1 INCA OUTLETS
Polity N_ [ ��7C� -PARK ME RECEII'TN
COnv /'/)LIr le'/1 .-w7 GAS FA.SYSTEM-OVER dMAI
BUILDING DIVISION FEES
LJffe py V
e5lffeelffiedi copy v fila withh the
herebyte city inspection division.ehd. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRA' PAID
COMPENSATION INSURANCE
CTMssection need not becompletd tithe permit Lsforonehundrd dollars SEWER-SANITARY-STORM FA.700Fr, Date Recei t#
($10D)orless) WATER HEATER W/VENT/ELEGTR ENERGYFEE Y N_
1certifythat othe persnInaerformance of(hsonerforwhkhthispemdtis cTaut, —
1 shall not employ any person in any manner w as to become subjetl to the
California. WATERcrs'Compensation laws of CalifoData WATER sYSIEM/rREAnlvc PAID '
O Z Applicant
Z 0 NOTICE TO APPLICANT-.If,after making thin Certificate of Exemption,you NEW RESIDENTIAL ELM B.__SQ%F. Date Recel t#
should become aubFct to the Workers'Compereatlon provislons of the Labor W TOTAL:
W Cdeme
,you at forthwith comply withsuch provisions orthis permit shallbe> deemed revoked. !ELECTRIC
G FE
CL G CONSTRUCTION LENDING AGENCY FM
EE hereby affirmthat there isoconstructton lending agency for the perform, TOTAL: FEEZ ance of the work for which thin permit V issued(Sec.3097,Civ.C.)V 0 Lenders Name G FEELL f Lenders Address QTY. MECHANICAL PERMIT FEE ICAL FEEOW lcertifythatlhavereadthisappliatio d-dgatethattheaboveinf.m tI..incorrect.l agreeto comply with ail city and county ordinanm and state laws PERMLTISSUANCE D:relating to building construction,and herebyauthoriurepowentativesofthiscity enter upon the above.mentioned property for me ion purposes. ALTER OR ADDTO MECH.gree to aave,ircl ty an d keep harmless City of Cupertino Receipt#
a i t labllltles,' 7rd., eased penis wht ykanywayaccrue AIR HANDLING UNIT CFO IOp00 CFM)
sad city Iona sating,, permit. SUBTOTAL:
ARHANDLING UNIT(OVER 10,0DOCEM) CONSTRUCTION TAX
%nah?Fe'of Appilant/C ntra&or Date EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HAl RDOUSMATERI LSDISCLOSURE
Willtheappliantorfutummolding oc ant attire Orhandlehaaardous HEATING UNIT(TO IDg000 BID)
.mrklasdefuwcbylhe Cupertl nitlpal Code,Chapter 9.12,and the Date ReceI t#
lkalthand Safety Code Secti 37(x)7 HEATING UNIT(OVER 100,000 BTU) TOTAL.
❑Yes o I
Will the applicant orfuture building occupant use equipment or devices VENTILATION FAN(SINGLE REMD) ISSUANCE DATE
which emit hamrdmaa irmntamlw s defined by the Bay Area Air
Qu lityManagement DisMdl BOILER.COMPQHPOR 100,000 BTIJB i!
4Yea o A
havercadthJUI ousmaterialsrequirementsunderChapter6.95of BOILER-COMP(OVER 100,000 BTU)
A. bilitybon
mia Health4,Silely Code,Setlions 75505,25533 and 25536.! C`e
d lhatifthe Wilding does not car nil have a(enant.that It is my NEW RESIDENTIAL MECH. SQ.FT G9 't
BYthe pant o(th rcments which must be matt uance a ate pa C1ryjFCUP,whori. age t Date
TOTAL:
ISSUEDe
OFFICE COPY