23927 'APPLICANT TO FILL IN INFORMATION WITHIN RED LINES --m- USE BALL POINT PEN.ONLY '
Building Project Identification PERMIT NO. '
Building Adtlress:
wn me one _ . .a -
CITY OF CUPERTINO-BUILDING.DIVISION' .��
cent/r��y\ �/y(/� f No APPLICATION I PERMIT.)
BUILDING-ELECTRICAL.PLUMBING-MFCHAMCAL CATEGORY CONTROLN
Architect/En neer. _ L c.No -
t;r `" t li t - "4 g
/tl - (QTY " , GGHCTRIC FERMIT' �' E'.�• +` 't BUfLDWGtP.ERl4t'T4NF0'
. Aaaase: t -PFRMITISSIJANCE / ;
LICENSED CONTRA 'SDE RATION - y
Iherebyaffirtnthatlamlkensedunderpr b,ons ofChapter9(comment- APPLIANCES-RESIDENTIAL JOB DfSCRI'I'ION
Ing with dton MW)of Divislon3ofthe Businessand Profess[onsCo e,and my
Llcer` 1.1.full force and effect. PANELS' �GaLJ�s Ds.!
Licensn - .Lk.N - -
Date Contractor - r
CHITECPS DECLARATION 701-1000 AMPS
a CZC I understand my plans shall be used as public records. "' OVERIOOBAMPS .„. FnOLRVI5/SQ.FT.
00
`j Llansed Professional 0 SIGNSELFCTAICAL .t t 01 �� UTE
JII pC�
„ 6 OWNER-BUILDER DECLARATION ` - .,. SPECIALCIl2CUIT/MISE s A 1'li '
[., Iherebfftrm
yathat I am exempt from the Contras rs License Law forthe
following reason.(Section 7031.5,Business and Professions Code:An d or ' g2,. '
OZe. w i ty TEMP.METER ORPOLE INST. 2"
�,�p countyMich requliesa permitto construct,alteq lmproJe,demoibA,orrepalr
HOPanystm=mpriortoltsbsuance,alsomquirestheappliantforsuchpermttto POWER DEVICES
ES O C.U file a signed statement that he b licensed pursuant to the provisions of the
C0u' Contradora License law(Chapter9(commeneingwith Secthm7000)af Divi- SWIMMINGPOOLELECTRIC '
OQ elon36flhe Busineesand ProfessbnsCode)arthat hebexempttherefromand _ - VALUATIf1py„`
Q the basis for the alleged exemption. Any violation of Seaton 7¢11.5 by any OUTLE7SSW[TCHESFIXM2E5
appltwnt fora permit subjects the applicant to a civil penalty otos more than
five hundred dollars(5500). NEW RESIDENTIAL ELECT �,IT, STORIVE4 J "-TYPE CONSTRUCTION "r
�j.. M I,as owner of the property,or my employees with wages as their sole _
compensation,whldothe work and thestrusure b not intended or offered for
- ..
O ask(Sec.7044 Business and Professions Code:The Contractors License law
. �, docs not apply to an owner of property who hu lids or improves thereon,and OCC GROUT' RFS.[INKS
who does such work himself orthrough his own employees,provided that such ,
improvements are not Intended proffered for sale.If,however,thebuilding or •.;T) .�•' r
Improvement Esold within oneyearofcompldioMtheowner-bdllderwillhave ° +
tryW„�n,raenofpmving that he did not build or improve for purpose of sale.). QTy;'•.,, ,*`t P�,I1I01BINGiPHRMIT t +'�,•;wEE '
LJ I,as owner of theproperty, :-FLOOD LANE - APN
Se exclusively Business
ess andProwith C PERMIT ISSUANCE
contractors;tois Limn the w doe(Sec.app?Businessand of prop Profession Costs;The Contraitor'c Limnos law does net apply to an,owner of property who ALTTR-DRAIN&VENT.WATER A)
'(EA'
builds or improves thereon,and who contracts for such ptojem with a as t , •y ,
on ctor(s)licensed pursuant to the Contracture License Law. = - ,'74ttt itt }yFEE.SUMMARY,.., ,i yai
LJ I am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE _
DRAINS FLOOR ROOF,AREA,COND. SANITARY'_ Y— N— -
Owner Date RECEIPT
WORKMAN COMPENSATION DECLARATION FIX'ITRES PER TRAP SCHOOL FAX Y—-N
❑I hereby affirm that I erve.eaviouncleate of consent to op therem03r a RECEIPT# ~
cartifiLabcate ofWorkers'Compensationlnsurana orarerti(Ied copy thereo((Sec. , GAS EA.SYSTEM-]ING.4 OUTLETS - PARK FEE Y— N_
3900,lab CJ -
PoliryN GAS EA.SYSTEM-0VER4(FA) - RECLR'TN
C y _ ` 'BUILDING DI VISION FE ES
Allied copy b filed w th the city i GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE ., "
Codified copy Is here with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID,.,:,
COMPENSATION INSURANCE SEWER SANITARY STORM FA 200FT - - Date Recei I71 '
(Thissectlon need not be completed l((he perrtd[bforone hundrctl doilare :
ENERGY
WATER HEATRRW/VENT/ELECTR PEE Y N .
lartl(empothe pe Ichthis permitblssued, —
I shall not employ any a er o o become subject to the WATER SYSTEM/TREATING
rkers Compensate ( Ilio nia PAID
O Z IlCant n -
NEWftFSIDLNT[ALPLMB. SQ}T. - Date,' Remi tN
Z O TICE Tomesit tt.thvak Certlflaleolonsoft eLaboon,you TOTA '
F Codo ounnua of wit the plywit'Comp roviednprothis po oRs Labbe 1,
VI Code,you mutt hwith comply with such pmvbions orthla permit shall be
deemed revoked. ,. BU TNG '•
dG CONSTRUCTION LENDING AGENCY - c SEISMIC FEE _
I hereby affirrethat there b a construction lending agency forthe perform ELECTRIC FEE
TZ
Z 'ante ofthe work for which this permit b issued(Sec.3097;Civ.C.): • TO
V O , fender.Narre - - - PLUMBING FEE. :
IL I— LenaersAddresa Q1Y. MECHA ICALPERMIT t:`•'FEE'Tt MECHANICAL FEE
O W Ianllythatl have readthisappliwtlonand statethattheabe I formaiton
C correct.Iagreetocomp)ywith allcityandmuntyordinancas and state laws PPRMITISSUANCE PEES PAID;
} relating to build[ hereby authorize representatives of this
h N city to enter up the above-mentbne rty(or inspect ion purpoxs.' ALM OR ADD TO MECH.'
(We)agree ndemm d keep as the City of Cupertino Date Receipt#
V agalnstllablllt s, d o s expe s h may lnanywayaocme AIR HANDLING UNIT(TO IOpW GEM) SUBTOTAL:
agairets9ld ity n u rep a o his permit.
AIR HANDLING UNIT(OVER 10,000CIM) CONSTRUCTION TAX
ignatura fAppuwnt/contra Dace IXHAUST HOOD(W/DUCT) - CONSTRUCTION TAX PAID:
H US MATERIALS DISCLOSURE - '
Will[ eapplicanl or future building occupant store or handle hazardous HEATING UNIT(TO 1(10,000 BTU) Date ReCL'1 tb
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
I lealth and Safety Code Sed[on 25532(a)? HEATING UNIT(OVER 100,000 BTU)-, .'TOTAL:
❑Yes r]No `
Willthe applicant or future building oempantuse equipment crievims VENTILATION FAN(SINGLE RESID); .ISSUANCE DATE
which emit harardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP(3HP OR 100,000 BTU), •P
Ihavee reaz
ad the hallo❑usomaterials requiremenes under Chapter 6.95 of BOILER-COMP(OVER 1W,0(A BTU) ) � "� I ®
the California Health&Safety Code,Sections 75505,25533 and 25534.1 , -understand that lithe building does not currently have a tenant,that it is my NEWRESIDENTIALMECH. 9Q.6T , JULJ -
responsibilitytonolilythe occupant of the requirements which most be met Jn
prior to issuance ofaCertlEwte ofOmpanry. 19,
Owner or authorized agent Date
ISSUEDBY:
OFFICE COPY