23162 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building project Identification PERNUT NO.
Building Address; 23162
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r7e4rJG/S 6xjlt4CC— Y OF CUPERT[NO BUILDING DIVISION
Contractor'sName: / N. APPLICATION /PERMIT b�_L
f�joa—r— 'i3LDINGELECTRICAIPLUMBING-MECHANICAL CATEGORY CONTROLN
rchlteci/ gineen ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: MITISSUANCE ❑LICENSEDCONTR under rDECIhercection7000).by ffl.that l iv Icensed 3.(the usines andProsions ionsCoPOANCFSRESIDENTIAL ]OB DESCRI'TION
Ing with Section 7000)o(DlWslon3.(the Budnesaand ProleuloneCode,and
LImAis In ml(o¢�and effect. PANELS
License Clan_�Q_LICY & 1�V
Date COntactur_ b
ARCHITECTSDECLARATION 00AMI'S OO Iundentand my plaushaB4used upubllcremOVER
rds. OVER 1000 AM['S SQ.FT.FLOOR AREA -t/SQ ET.
oU Licensed Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
follX Ihercby.ffl.thatlamexemptfromtheContratlor'.LimnwU.torlhO L ED ' N
owing reason.(Section 7031.5,Business and Professions Code:An cit or
F •'qq count hkhrc iresa rmltwmmtm p y TEMP.METERORPOLEINST. e'�'ER
� q you qu pe uinuthea rovgdemolbh,erre it
y ❑❑
anystructure stapritement
that
he is alwrcq pursuant to the fonuc fiatofpermit e pOWpJ(DEVICES
C�� llie a signed statement that he b licensed pursuant to the proWsbu of the
Ow Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi.
�0 sion3ofthe Businenand Pro(esslouCode)arthat hebexempetherefromand VALUATI
SWHMNC POOL ELECTRIC
yd the basis for the alleged exemption. Any violation or Section 76HS by any
applmntforapemdtsubie theappllcanitoadvllpe�ltydnam mthan OUTLETSSWITCHESFIXTURES
five hundred dolhn($5fe).
NEW RESIDENTIAL ELECTS SQ.FI.
�n ❑Lasownerolthe thewor and my employees 1, with wages dedor offered
sets fo STORIES TYPE CONSTRUCTION
mm(Sec.744,willcloBusiness work and the etmctumbnotintended orofferedfor
p sale(See.apply
Business and f property
rops ty Code:The C improves License Law
does rig
who does
apply roan owner of through
OCC.GROUP RFS UNITS
whodoesDuch work tInteBar ornagh Mownemployees,providedthatsuch
Improvements are not Intended proffered prole.If,how er-buhebuRdmgve TOTAL:
Improvement bsold wlthinoneyearofcomplelion,the owner-bulWerwlil have
the burden or proving that he did not build or Improve for purpose orsale.). QTY, PLUMBING PERMIT FEE p[.OD ZONNE APN
LJ L as owner of the property,am exclusively contracting with licensedPERMIT ISSVANCE
contractors to corutruct the pm)mt(Sec.7614,Bualnesa and Pro(esslou Code:
The Contractor's Limnae Law dues not apply to an owner of property who ALTER-DRAIN&VENT-WATER mA)
Wild.or Improves thereon,and who comment for Duch p(o)ecis with a
BlfaRor(s)Ilcamed punuut to the Contractor'.Limme Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
cg
LII am exempt under Sen B&P C for this moan
DRAINS FLOOR,ROOF,AREA,GOND. SANITARY Y N
OUTSIDE FE
Owner Date RECEIPFN
WORK MAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N_
❑I hereby elfimn that I have o Imum m or consent to o y thereof
ora RECEIPT N
3enlfia3800, b of Warken'Compeuatlun lruunnce ora certified mpythereof(See / GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
I'OITry N GAS FA,SYSTEM-OVER 4(RA) DING DI p
Com any BUILDING DIVISION FRGS
Certified copy 1.herebyfurnished.the city CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE
Certified copy b filed with the city Inspection division.
CERTIFICATE OF O(EM PTION FROM WORK ERS' CREASE TRAP PAID
COMPENSATION INSURANCE
(fhlsaection need nabecampleted lfthe permit bforunehundred dollars SEWER SANITARY STORM PA.I00F1'. Date Recei tit
(5100)rrf4AI ;
that
WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I cen .1.ormancoft ner forst this permit ieiwed,
I shall noon In n neer u t
me to the WATER SYSTEM/TREATING PAID
Worken' WsO 1 nm. (O�
O Z Appllant NEW RESIDENTIAL PLMB._SQ.Ff. Date ReCe1 t#
Z O NOTICE R, h t hg thio Certlfia/e o(Exemptlon,youshould bece Wo Compeu.it..provblmuofthe Labor TOTAL:
~ Code,yoummpl with such provisions orthb permit shall be
Ir 9 deomedrevoked,
BUILDING
a G CONSTRUCTION LENDING AGENCY 2ELECTRIC
EE
Ihembyaffirm that there b a construction lending agency for the perforrry —, FEE0 ante ofthe workfor which this permit b Wued(Sm.3097,Civ.C.) T EEE
L) Lender's NameIyF LOnder's Addmea QTY. MECHANICAL PER MIT FEE CAL FEEOW l certlfythat l have read this appliattan and statethatthe above information bcumat.I agree to complywith al city and county ordinances and nate laws PERMTTISSUANCE :
} 1 relating to building muWction,and herebyauthorizereprmnmtivesofthb o
Zcity to enter upon the aleve-mentioned prepertyforlupectlonpurpmsca ALTERORADDTOMECH. RCCCI tIt
Z (We)agree to save,Ind 7= an d kee armiess the City Of Cupertino F
:gamut llablllt dgmenm,costo and exp eswhkh ym.rywayamrm AIR HANDLING UNIT QO 16,000 CPM) SUBTOTAL:
:gamut sal ,ty n cense race of the gra Ing of th emnit.
• 6 AIR HANDLING UNIT(OVER HLODOCFM) CONSTRUCTION TAX
Slgnatu IPp t/ antra — Data allAUST HOOD(W/DUCI) CONSTRUCTION TAX PAID:
HAZARDOUSM ALS DISCLOSURE
Wills Ppllant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BN) Date RCCEI f
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the
I lealth and Safety Ccdlon 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTA
❑Yea
Will the applicant 1&Ko building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hav nkm,.1,cuntaMunt..,deo red by the Bay Area Air llizpp pp
. IityManagement District? BOILER-COMP OFT'OR 100,000 BTU) P M i D
Yes No
shave mad the mar ? cmmrfals mqu lmments under Cha pter 6.95 of BOILER-COMP(OVER 100,600 BTO ��� oU 1x99
the California Health&Safety Code,Sort lona 25505,25533 and 25534.I 1(171
under.mnd that lithe building does not currently have a tenant,that itis my NEW RESINTI
DEAL MECH. IT
SQ. .
rnPomuibi to nmtlfyt ocmpant o(the quirem mwMch mull be met
pdorto a ceofa IficateofOcm V. L CITY UI- uur HI
Ownn au mrized agent - Data —� TO ISSUED BY:
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OFFICE COPY