23734 AFFLIfLeANI lUrILLIF4lF4rUKMAIIVF4WIlrIIF4KrWLlF'irJ — UQCDa "" rW41NI
Building Project Identification PERMIT NO.
Building,�ddmcs:
-> p%S" 23734.'nen ame:
7
one:
CITY OF CUPERIINO-BUILDING DIVISION
Connector's Name: Lk.No: APPLICATION / PERMIT
BUrLDINr-ELECTRICAIPLLTMBINr-MECHANICAL CATEGORY CONTROL#
Ambited/FnIarear. Lk.N.:
I."'
jj
ELECTRir-PE BUILDING
-PERIVIITANFO'
BLDU hLl�i PLUMB M�H
Add. LICENSED CONTRAC7IOR'S DECLARATION PERMITISSUANCE LJ
0 0 D
I"by affirm,thati go licensed urge,prowlsicats of chapter 9(comarmeno. APPLIANCES�RESIDENTIAL JOB DESCRIPTION
Ingwith SeMon7ODD)o( si=3oftheBu,i�andPmf�=sCode,and my
ltmaagi.in fullformandeffiect. PANES
License Class Lic. e,�V�Wt4j
Date CoMa=r UP TO 2DO AMPS au;
ARCHITECT'S DECLARATION 201-1000 AMPS SQ.FT.FLOOR AREA $M.FT.
Z I undembind MY plara.latll be used an publi.moords. OVFR1000AMP5
00
Licensed Proffinational SIGNS ET ECTRICAL
tr'<s.u2'fLo OWNER-BUILDER DECLARATION
that Iam exempt from theContrame,License Law forthe SPECIALCIRCU[T/MISC
I hereby affiren
t.
following nanor.(Section 7031.5.Business and Professions Code:Any city or
TEMP.METER OR POLE INSr.
cauntywhich requiresa peradtancturstruct,alter,improve,demlbh,wmpgr —
.Yst .prbrwiftlevranc"bomquLmtheapphmtforsuchperdtto POWER DEVICES
file a signed comment that he Is limmand pursuant to the provisions,of the
Ioff t.
Cantractan's License JAW Chaptang(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATE
the baste(or the alleged exemptiar. Any violation of Section 7031Z by say
�n3oftheBu�mmdP�m�mC�e)orthgheb�mptthemfmmimi
OU1`LETSSWI7CHES-pTx6& 7- r-
1.02 �Lo 00
ppL.tf.r�p.�t.b*Uth�.ppH..tt..dwlp�.1tya.�..t�.
five hundred dofflars($500). NEW g7IAIEL 7 STOFJR5 TYPE CONSTRUCTION
E]L n owner of the property,or my employees with wages as their sale
compersation,willclothe won�,and thestructurs,is not intended or offered for
I.(Sec7016,Busisma.rul I'mfisaclom Code;The Cortractoesticens,Law
does not apply to an owner of property who builds or Improves thereon,and DATE OCC.GROUP RES.UNITS
who doentsuch work hicaselforthrough hisown employees,provided that each
improvements am not Intended or offered for sale.It however,the building or TOTAT-
Improvement bsoldwth�omynrofc=pleio�the�er-bufldcrwUI have -11 11 '.11 1-1- 1. -1.t 11 - .".- t
t"rdenofEramingthathe did am build or improve for purpose of sale.). Qry, -PLUMBINCTERNUTi:�,"% 4i,- FEE E FLCOD ZONE APN
Lj I,as owner of the property,am exclusively contracting with licensed
mnnactonto romtmq the project(Sec 7046, goes and Professions Code: PERMIT ISSUANCE
The Cmuramn'.Lt..Li.4m not apply to an owner of property who —
builds or Improves theater,and who contracts for such ptojects with a ALTER-DRAIN&VENT-WATER MA)
coy l[a.ctorls)hemsed pursuant to tie Caglarachor'.Licerme Law. BACK FLOW PROTECT.
LJ tem exempt under Sm.8 &P C for this reason — DEVICE OUTSIDE FEES
Owner Data DRAINS.FLOOR,ROOF,AREA,CONTI. SANITARY Y— N—
RECEIPT
041T,- z I
WORKMAN COMPENSATION DECLARATION Y
711 hereby affirm that I have a certificate of...seat to self-Wore,self-Wore,.,. I FDCTURES.PER TRAP SCHOOL TAX — N—
ardfimeofWo,k.n'C� �
peHonI�mwmamnifiedwpythemf(Sec. RECEIPT#
38W,lAbC.) GAS.EA.SYSTEM-1 INC-40UTLErS PARK FEE Y— N
vtYPolicy 0 RECEIPT#
an a GAS-EA.SYSITM-OVER 4(EA) BUILDING DIVISION FEES
Certifiedi copy is hereby furnished. GRFASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
OCerlifted copy Is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date Remipt#
(Thisseedonneed not becomplated lithe permit is(orom hundred dollars
W00).sless.) WATER HEATERW/VENT/ELECTR ENERGY FEE Y N
I certify Nat in the performancrafthework forwhich this permit is issued,
Ishallnotemployanyperson inany manner soutobecoamabject tothe WATER SYSTEM/TREATING PAID
WorkersCompersufflonLitwitofC.1iforatia.Date
0 Z Applicant NEW RESIDENTIAL PLMB.—SQpr. Date Remipt
Z NOTICETO APPLICANT.If,after cruld.pithfiCerfificte.flixecaption,you
2 should becomes subject to the Wortuers'Compernation provisions of the Labor TOTAL: I
Ln Code,you a,forthwith comply with such provisions;or thin permit shall be L+
> deemed..ked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
(L 1 hereby affirmthat them is a caramnictior,lending agency for the perform, ELECTRIC FEE
D Z ...fth.wrkf.rwhichthbpe�tbimadCSec.3W7,Civ.CJ TOTAL
L) 2 Landi-e-Name PLUMBING FEE
I crarki"at I have mad this application and gate that the above irfornotion MECHANICAL FEE
U. La.dce.Add QTY.
0 iscomot.I agmetocomplywith all cityand courtyonfirAnOmAnd atatelaws PERMIT ISSUANCE FEES PAID�.
>- relating to bulldmg construchoo,and hereby authorize representatives of this
V) city to enter upon the above,mg,tioned property for Inspection purposes. ALTERORADDTOME.CH.
(We).9ree to save,indemnify as If lamp harmless the City of Cupertino Date Receipt#
i..yw.ya.a AIR HANDLING UNIT(TO 10,000 CPM) SUBTOTAL:
ag.matCfty in car-ace of the gm&ir7g got P. AI
s0a2R HANDLING UNIT(OVER 10,ODDCFM) CONSTRUCTION TAX
/'
Signaturiod Applicart/Contractor Data D(HAUSTHOOD(W/DUCI) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willtheapplicard or hinum building occupant stomorhandle hazardous HEATING UNIT CFO 100,0DORTU) Date Receipt#
material as defined bythe Cupertino Municipal Code,Chapter 9.12 and the
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BW TOTAL.$-t S-tsa-
[:]Yes t�l No
Will the applicant m future building occupant use equipment or devices VENTILATION FAN(SINGLE BUD) ISSUANCE]51ATEL)
which cout hauardous air cartansmantsas defined by the Bay Area Air
11jahly Management Districtl BOILER-COMP(3HPOR 100,0(0 BTU)
qbY. ad the b.9 No BOILER-COMP(OVER 100,000 BTU) KAY27 -
have us materials requirements under Chapter 6.95 of
ifornia Health&Safety Code,Secktra;25505,25533 and 25534,1 1992
hdarsts ad that if the building does am cammtly have.teas rL that It Ja my NEW RESIDENTIAL MECH. C11 rL,
-I-insporgIbUity to notify the occupant of the requirements which must be met yr
UrG
nortoissuanceofaCertificateof0couparty,
w authorized agent TOTAL: ISSUED BY.-
OFFICE COPY