23355APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pn'ect Identification
PklL50T NO.
Building Address:
-3-
23355
hone:
[4_l )( cL. C'\gTF ti
CITY OF CUPERTINO- BUILDING DIVISION
APPLICATION / PERMIT
BURLDINGELECTR CALPLUMBf\GMECF AN CAL
A S A A
—1 Z
Contractor's Na mc: Jr}L1c No:
CATEGORY
CONN OL X
n-niie, r. Lec. No:
•QTY• ELECTRICPERMIT ,.'- -FEE
BUILDING PERMIT INFO:.' -
PERMIT ISSUANCE
Address:
❑ ❑ El
CONTRACTOR'S DECLARATION
ON
hereby afflrmthm
at l alicereed under prolsionnor Chapter9(commune
'ngwith5cctlon 7fNlWor Divislon3otihe Businessand Pm(esimn Coda and my
license is in futl{orce and effen.
Li Cl.. Z��Lie.N_or
APPUANCESRESIDENIWL
ESC
JOB DKI'ION
VJ FP -
PANELS
Date Contractor
201.1000 AMPS
ARCHITECPS DECLARATION
I undenta cad my plarushal be used as public records
Licensed Professional
OVER IODO AMPS
SQ. FT. FLOOR AREA
E D I N
$/SQ.FT.
SIGNS ELECTRICAL TIUK
SrFCL1L CIRCUIT/MISC
OWNERA
BUILDER DECLARATION
I hereby affirm QutIamexempt from the LARTIO License Law for theCOM
UTE R
following Mason. (Seetion 7C31 S, Business and Profession Code: Any city or
countywhlch requires a permit to mmtmo, alter, mpmve, demolbh,ormpair
7FMp.MEfER OR POLE INST.
any stmnure prior to Its Issuance, also requires the applicant for such pemduo
file a signed statement that he Is Hconed pursuant to the provision of the
POWER DEVICES DA TE
.
SV.'LM{MING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
Contrzctari License Law (Chapter 9(commencing with Section 7000) of Divi-
sea n3of the Bualness and Profession CoddortM1al M1ebeumprtM1emfromand
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora permit subjem the applicant to a civil penalty of not more than
VALUATIQ"j��
i/11 _ CSC...
LL JCa\�1/
NEW RESIDENTIAL ELECTR �'�'
rue hundred n I of heSOW.
PI, as owner of the property, or my employee with wage as these sole
STORIES
TYPE CONSTRUCTION
compenation,Z Hl do the work and the structure is not Intended or offered for
sale (Sec 7004, Businessand Professbn Cade: The Contractor's Lt.. Law
does notapply toan ownrof property who bitildaar improve thereon,and
himself orthrough hisown employees, provldM that such
OCG GROUIr
RES. UISwhodoessuchwork
TOTAL:
improvements are not Intended proffered forsale. If, however, thebuilding or
Improvement hand withinoneyearofmmpleWn,theowner-bu0derwill have
Ihq�arden of proving that he did not build or Improve for purpose of sale.).
LI 4 as owner u the property, am exclusively els and contracting with encased
to construct the project (Sete and rf am Code:
'QTY. -�'_ PLUMBING' PERMIT.- - aFEE.''
FLOOD ZONE
ANN
PERNITISSUANCE
TheconContractor's appl70Ky
to in o pro
Wil Contrempr o License Caw don ear apply tct an owner of property who
Wild, or Improve therems, and who mnemes for such projens with a
cgLt.�actinexlicensed to the Contranors License Law.
under
I_I I am exempt under Sec B & P C for this mason
ALTER -DRAIN & VENT- WATER MA)
-
uFOUSUEFEES [;,-,^k'r(
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, CONE.
SANITARY Y_ N
RECEIPT#
Owner Date
WORIGMAN COMPENSATION DECLARATION
.L,t revjs!Iflm: that I have a mrtiMate of consent to sell -Imre, ora
cendicateofW.:'ters'Comperuatlon insurance or a certified copy thereof (Sec.
3800, S,.L. ^ql^_' ,�
f `U
FDnIJRRS PER TRAP
SCHOOL TAX Y_ N_
RECEIPT N
GAS E.A. SYSTEM -I INCA OUMETS
PARK FEE Y N
RECEITN
Policy#
P011ryp
Com
-al
anv V2� dU�rf H�u�V
GAS EA. SYSCEM-OVER4(EA)
BUILDING DIVISION FEES
rtiied copy b hereby furbished.
emirea ropy b riles with the cry inspection division.
WASTE INTERCEPTOR
PLANCHECK FEE
-CK
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
SEWER -SANITARY -STORM FA. 2f10FT.
COMPENSATION INSURANCE
This section need net W completed I the permit Is for one hundred dollars
Date Rewi tii
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y_ N_
(S10Worless.)
I certify that N the performance of the work for which this permit Is blued,
WATER SYSIMNUTREATI<G
1 shall out employ any person In any manner so as to become subject to the
Workari a L Compensatk iw.oteaBfnmia. Date
PAID
NEW RESIDENTIAL PLM1IB. SQFT.
Applicant
NOTICE TO APPLICANT: Ima
, after king this Certificate of Exemption, you
should become subject to the Workers Compematim provisions of the Labor
Date Remi tN
TOTAL
BUILDING �•
Code, you most forthwith comply with such provision or this pernbtshali be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I hereby atfim that there Is a conrroctlon lending agency for the perfartry
ance of the work for which this permit Is issued (Sec. 3097, Civ. C.)
lender's Na me
Lender's Address
I certify that I h iveread thisapplication and statethat theabove Information
Is correct. l agree to comply with all city and county ordinances and state laws
TOTAL:
ELECTRIC FEE
PLUMBING FEE
QTY. LMECHANICAL PERMIT '; FEE '.
MECHAMCALFEE
PERMIT ISSUANCE
FEES PAID:
relating to building construction, and hereby authorize representative mf this
city to enter upon the above,mentioned propeny for inspection purposes.
(We) agree to save, indemnify an d keep harMess the City of Cupertino
against Habilltin,judgments, consand expense which may In any wayaccroe
Date ReaeipHl
ALTERORADDTOMECH.
AIR HANDLING UNIT (TO 10,ODO CFM)
SUBTOTAL:
againtsaid City In naequen hhe granting of this permit.
AIRHANDLUNGUNT(OVERlQ000CFM)
CONSTRUCTION TAX
sig o ppH unm Date
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
A7ARDOUS MATERIALS DISCLOSURE
11thca (cantorfuture building occupant store or handle hazadous
Date ReCel IR
HEATINGUNIT(T0100.00(i
-
material as defined by the Cupertino Municipal Cade, Chapter 9.17, and the
Health and Safery Code Semon 75532(a)>
❑ Yes N NO
Will the applicant or room building occupant use equipment ordevlces
HEATING UNIT (OVER 100,000 BTU)
TOTAL
VFN7TLATIONFAN(SINGLERFSID)
�1$SU.&NIdE DATE
which emit havrdon air contaminants as defined by the Bay Area Air
' J4'YManagement District?
es
J -Pae read the h.9 N matcnab requirements under Chapter 6.95 of
BOILER -COMP OIPOR 100," BTU)
BOILER -COMP (OVER IOQOOO BTU)
a G. -, arnla Health &Safety Cade, Seniors 25505, 75533 and 75534. 1
understand thu if the building does not currently have atcnanq that it is my
responsibility cat of the requirements which most be met
the occuirate
SI I (,Y j,UY G(tI IIJU
NLW RESIDENTIAL MECF i. SQ.IT
riorta ce of a o
Pitot to issuance of a Certificate of Ompanry.
ISSLEDBY
Owner or mthoriud agent Dale
TOTAL:
OFFICE COPY