23505 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project IdentificationPERMITNO. '
Bund+ng Ad s: /JQ� Q/-� Xv� _ 23505
n e amt: AA //�I/ o A
CITY OF CUPERTINO-BUILDING DIVISION n��J
c��/�ctm'c Name: - Llc.,[(J.: APPLICATION If PERMIT L-ts-�-. lZ.
"" a� r ��AS1 BUILDINGELECTRICALI'LUMBINGMECHAh7CAL CATEGORY CONTROLM
Architect/Engineer.
Lie.No:
//n/J--// r QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: OQ eC GCr �9,-J/Z PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby af(irmthat l am licensed under provisions of Chapter9(cvmmen APPLIANCES-RESIDENTIAL JOB DFSCRIPHON _
+ngwith Section 7000).f Dlvlsion3oflhe Businessand Profesalons Code,and my GLVB
license is in f Ij rce d affect. pppp 6 PANELS v
Date G.nlrad.r PS
ARCHITECTSDECLARATION OVE0W AMPS
0 O❑❑ I understand my pons ahaB be uaM a public recoMa. OVER If00 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
NO Licensed Professianal SICNSELECTRICAL
�Z
<w OWNER-e UILDER DECLARATION 9sEC1ALCIACUIT/MISC
7 s., I hereby affirmthat Ia.exempt from the ContractorsLimose Law for the
pp following reason.(Section 7031.5,Business and Professions Code:Any city or
O y F TEMP.METER OR POLE INST.
G� oauntywhich requires apertnitt.corutruct,alter,improve,demolish,orrcpatr
a anystructure prlorto its Issuance,aborequireathe applicuntforsuch permoto POWER DEVICES
U file a signed statement that he Is licensed pursuant to the provisions of the
OwI� Contredore License low(Chapter9(commencingwith Seclion7000)ofDlvl-
�OJ Mlan3 oftheBueiness and ProfessionsCode)orthat he is exempt therefromand SWIMMIKG POOL ELECTRIC VALUATION
•33 the basis for the alleged exemption. Any violation of Section 7031.5 by any
Q OUTLETSSWI7'CIIESFLYIVIiES
applicant for a permit subjects theapplicant too civil Pena By of net more than
lay five hundred dolhre5500 NEWRESIDENIIALELECTRSOWFS TYECONSTtUCT10N
p^, ❑I,as owner of the property,or my employees with wages as their cele SQ'FT'
compensation,will do the work and the structure Is not intended or offered for
sale(lice.700 Business and Professions Code:The C.soadoes Llmnse Law
Q does not apply to an owner of property who Wilda or improves thereon,and OCC.GROUP RIS.UNITS
who does suchworkhimxlforthrough hlsownemployees,provided that such
improvements are not Intended oroffered forsale.If,however,thebuilding or TOTAL:
Improvement bsold withinoneyearofcompletion,the owner-bullderwlll have
thnt4uNen of Lowing that hedid not bund or improve for purpose ofsale.). QT-Y. PLUMBING PERiVIT FEE pl-Opp PONE A,,LJ L as owner of the property,am exclusively coed
contracting with licens
mntrectore to construct the projed(So.7044,BuMlnessand Professl.ru Code: PERMITISSUANCE nit
The Contractors License Law does not apply to an owner of property who I 'I
p n,and who contracts for such piujeds with a ALTER-DRAIN&V -WA
bulkis to Improves;there. ) I FEE SUMMARY
,lB�acimeIlmpt pursuant to the Contractor's License Law. i.r
LJ I am exempt under Sec. B&P C for this reason BACK FLOW PR OT��T.DFrVICE I �
OUTSIDEFITS
Owner Data
DRAINS FLOOR ROOF,AHFIA,CON BJI MTARY Y N
_
WORKMAN COMPENSATION DECLARATION pp(NRpS- TRAP LTA RECEIPT#
Y_ N
[:]I hereby affirm that I have a certificate of consent to self-Iname,m a RECEIPT M
certifimteofWorkers•Compensationlnsuranmmamrtifiedmpythemof(Sec. CAS EA. INC40UTLETS PARK FEE Y N—
P
GbCJ RECEIPT#
C. 1� G�G�_ GAS P.A.SYS
TTMTMh OVER4(EA) BUILDING DI VISIONITES
[ ertlRed copy is herebyte GREASEANDUSIRL WAS I£INTERCEPTOR PLANCHECKFEE
s❑C'edlled copy b filed withh tthhcity
e city Inspection division.
CERTIFICATE OF EXEMPTION FROM WOR KERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.20OFT. Date RC i t#
Qhia secilon need nut b completed lithe perMt b intone hundred dollare
(5100)orlms.) WATER HEATER W/VENT/ELECIR ENERGY FEE Y N
I certify that In the performance of the work for which this permit is issued,
I shall not employ any person In any manner so as to become subject to the WATER SYSTIM/TRFATING
Workere'Compenaatlon Laws of Gllfornb.
Data PAID
O Z Applicant
Z LD NOTICE TO APPLICANT:ILafter making this Certificate of Pxemptlan,you NEW RESIDENTIAL PLMB.__SQ.FT. Date Recei t#
1"' should become�ubject to Work<n'Compensation prov1I of the Labor TOTAL:
N Code,you must forthwith comply wlthauch provisiomorthB permit shallbe ^�
] deemed revoked. BUILDING
aCONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby alOrm that there b a construction lending agency for the perform- ELECTRIC FEE
= Z anceoftheworklorwhlchthbpermitlslssued(Sec.3097,Civ.C,I TOTAL:
00 landa,.N. PLUMBING-FEE _
LL H Lender's Addeess QTY. MECHANICAL PERMIT ITE• MECHANICAL FEE
OW iscoI mrtifythat l have readthbepplicationand sbtethattheabovelnfovnstlon
G rred.I agreeto comply with all city and county ordinances and slate laws PERMIT ISSUANCE FEES PAID:
>. W relating to building construction,and hereby awhorm representatives ofthis
F Z city to enter upon the abovo-menti.ned property for inspection purposes. ALTER OR ADD TO MECH.
— (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
against liabilities,j,dgmenre,cart...d expenses which may lnanywayaccme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agawtMaidC Nmt cote ting.(this partnil PIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
mmrcol AppBcanl/Co� dor Date EKHAUST HODD(W/DIA:'D CONSTRUCTION TAX PAID:
1=1 OUS MATERIALS DISCI SURE
Will the applicant orfuture building occupant atom or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recti t#
material as defined by the Cupertino Municipal Code,Chapter 9.13,and the -
Health and Safety Code.s�Section 25532(z)7 HEATING UNIT(OVER 100,000 BTU) TOTA L
❑ Yes L_I No
Wllllheapplicant orfutumbuildingnttvpantumequlpment ordevices VFNI7LATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit harardous air contaminants as defined by the Bay Area Air
• Quality Management District? BOILER-COMP PTI'OR 100,000 BTU)
4 Yea n No
have read the haza ous materials requirements under Chapter 6.95 of BOILER.COMP(OV3R 100,000 BTU) ppyy
the GlifomW Health&Safety Code,Sections 75505,25533 a ad 75534.1 /� A
understand that lithe building does not currently have:tenant,that it is my NEW RINIDENTIAL MECI I. 5Q.FT PAJO
prior to Isu Issuance
Ceheompa ntoftherequlmmenb which must be mel APR
prior to issuance o!a Certificate o(Occvpanry. (j
Owner or authorimd agent Data V ,
TOTAL: -
OFFICE COPY