23812 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Address:
2/ '23812
3 Ca TILA)
nes ante: ne:
E�lq ONila ax , ]— 4 CITY OF CUPERTINO-BUILDING DIVISION ��J
Contractor. C
erre, LIcNn: APPLICATION /PERMIT --C !}•1
�
Qct M/4:M GO'� u�rla�/ BUILDINGELECTRICAleFLUMBINGMECHANICAL CATEGORY CONTROL#
And act/Engineer. Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add.. Y to. l r T. 5. S/IO PERMITISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm that l am licensed under provblomcd Chapter 9(rommen APPLIANCESRESIDENITAL JOB DESCRIPTION
than.] In fon to.a Divfect. flM1e Buelneuandlsro@WonsCade,and my
Lim ee Is in tali force and died. PANELS
Date Chs contr
Dale Contndor UPT02DO NTS
ARCHITECTS DECLARATION 701-IODOAMPS
q�q�uu M I understand my plensshall be used as public rccmds OVER 1000 AMPS SQ.FC.FLOOR AREA^^�`�+ f/SQ.FT.
k o Licensed Professional SIGNS ELECTRICAL I.
® ' O v
6 Fa
OWNER-BNLDER DECLARATION SPECIALCBICIRT/MIST —Ip 1110���
71.., E I herebyaRlrtnthat lamexempt fromthe Contudor'.Llcenm Lawforthe _ u� 11 k..[
p following reason.6edion 7031.5,Business and Professions Code:Any city or ' {
O'Z F TEMP.MEfERORPOLEINST.
F� oarntywhlchrequlreapermittommtmd,alteclmprove,demolhh,orrepalr
anystrodure prior to Ralesuance,also requlrestheappllcanl forauch permit to POWER DEVICES
O 5 Tile a signed statement that he is licensed pursuant to the provisions of the -
Contradoes License Law(Chapter 9(commencing with Section 7000)of Divl-
S�"In SWIMMING POOL ELECTRIC
OS the basis fo the
exemption.
Any
yviolation iseeempt therctrom and VALUATION
the bash for the alleged *Uth nn. Anyt to
of Section not room
by any OUTLETSSWITCHE -FIXTURES
applicant fora permit eubjeMthe applicant to a dull penalty of not more than
Ove hundred doIt..($sm. NEW RESIDEN IAL ELECTR
I,as ower of the property,or my employees with wages a their sole SQXT' STORIES TYPE CONSTRUCTION
7�aa rompsnutfon,willdotheworkandthestmctu ,isnot intended or offered for
sale(sec.7074,Business and Profesiora Code:The Con<ract.e.Llense Law
$ does not apply to an owner of property who Wilds or Improves thereon,and
whodoessuchworkMmeelforlhrough hisown employees,provided that such OCC.GROUP RFS.UNITS
improvements are not Intended oroffered(mule.If,however,thebuilding or TOTAL:
Improvement Issold within oneyearofcompletion,the owner-builder will have
Hi5J2urden of proving that he did not build or Improve for purpose ofsale.). QTy, PLUMBING PERMIT FEE FLOOD ZONE APN
U{as owner of the property,am emlulvely contracting with licensed
contractors to construct the project(Sec.7014 Business and Professions Code: PERMIT ISSUANCE
The Contradoes License Law doe,net apply to an owner of property who ALTER-DRAIN&VENT-WATER k?N
builds or Improve thereon,and who contracts for such pVojects with a FEE SUMMARY
�gp{(�ctor(9)11mesed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
L i sem exempt under Sec 'B &P C for this mason
Owner Data DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
RECEIPT&
❑I hereWORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOL TAX Y_ N
by afftrm that I have a certificate of consent to self-Insure,ora certificate,of Worker Compeneationlmurarm ora¢rtifkd copy thereof(See. RECEO'T N
3HW,lab CJ A �j /� CAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y N_
RECEIPolley# GAS�EA.SYSTEM-OOVER BUILDING DIVISION
Com env T x1/✓� BUILDING DIVISION FEES
�Certl�—copyb here th the city CREASEANDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
CertlOed copy b filed with the city Inspedlan division.
CERTIFICATE OF O(EMPTION FROM WORKERS' GREVSETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date RCCci t#
CChissedion need not becomplet d Rthe permit isfmom hundred dollars
(5100)or leve.) WATER HEATTRW/VENT/ELECTR ENERGY FEE Y N
Ill otthat.theppemoanceof lhework.aat.1btMspermitcit.th.
I ahem not employ any Laws In any manner n u to become sub)M to the WATER SYSTEM/TREATING
Worlicant Compensation Laws of California.Date PAID
0 Z Applicant NEW RESIDENTIAL FLMS. SQFT. Date Recei t#
Z O NOTICE TOAPPLICAM:R,after making perhis Ction provisions
Exemption,you
Fshould become mbject to the Worker Compenutlon prov&Ions o(Ihe labor TOTAL:
N Code,you must forthwith comply with such provisions or this pernet&hallW_ BUILDING FEE
W > deemed revoked.
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
]hereby orkfo wutt ich this
acoratroction d(Sec.agency 7,Civ.
.) perform- TOTAL: ELECTRIC FEE
0 Z anceer's the Nwork(or which thio permR is Issued(Sec.3097,CIa CJ
02 Lend.e.Name PLUMBING FEE
U. f— Lenders Addrcs QTY. MECHANICAL PERMIT FEE
O W Iertltythat]have read thleapp11ot1anancounty hat ordinances a dgat lam
FES AID: FEE
it, iscorrecl.lag to complywlthallcityand county ordinances and stale lawn PERMIT ISSUANCE r� - FEES]?AID:
} N relating tobulWi 9constroctlon,and hereby authorise representative ofthis
1 to em the above-mentioned m for Inspection purposes. ALTER OR ADDTOMECH.
Z `ty pO property F p"Cu Date Recei t#
lVs'e3 e o u ,ort, an d keep ha..Ielawhich the City y Cupertino
U
r.,=
sj menti s ea nugofth.meyInanyways due ARHANDL NG UNIT R010,OWCFM) SUBTOTAL:
Ityo( gofthspermt. AIR HANDLING UNIT(OVER l0,000CIM) CONSTRUCTION TAX
re of p to t EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
ZOU RIALS DISCLOSURE
theappRce m I Ing occupant store or hantlle hazzrdous HEATING UMTpO]fA,0008'HJ)l as dcifr!by the pertino MuMdpai Code,Chapter 9.17,and the
I Whh and S.f&y Cade Sedion 75537(+)7 HEATING UNIT(OVER life"BTU) I
OYes M Na
Will the appllcant or future building occupant use equipment ordevkcs VENTILATION FAN(SINGLE REBID) ISSUANCE DATE '
which emit hazardous air contaminants as defined by the Bay Area Air Ir 44�iC{ 9 LY
Quality Management Distrid7 BOILER-COMP OTE'OR 100,000 BT(1)
❑YeaNo BOILER-COMP 100,000 BTU) 1 ���
Ihavc read the Favrdoua materials requlremenb under Chapter 6.95 of IU 1 a/
C
the California Health&Safety Code,Sediom 25505,25S33 and 25534.1 JU�a Yv
understand that lithe building doe not currently have.tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT ell
responsibility tonotify the oo:upant of the requirements which must be met V Fur VUt1
priorto issuance d a Certlflcate of Occupancy. CI711I fIV
Owneror authorized agent Date JAI ISSUED BY: ___ • 7
OFFICE COP . /