23144 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Rulldin Fmect ldentlflatimt ', ,A PERMIT NO.
Building Addreea:,Q �'' � W14,P 23144
w ru-Te. u — one: APPLICA TION SUILMIr[AL DATE
��EGT r°. ' —166.5�D CITY OF CUPERTINO-BUILDING DIVISION
c.ntnd.r.wme: Lm.N. APPLICATION /PERMIT
Architect/Engineer Lie No: BUILDINr—CLECTRICALPLUMBINC-MECHANICAL CATEGORY CONTROL#
Q'ry ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add.. PERMITISSUANCE 01 ;^ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that lamlimmcd under preavislonsodChapterg(comment, APPLIANCES�RESIDEMIAL JOB DFSCRIPDON
Inurus1 in loo forceaf Divldon3 ofthe Buelrieseand Pro(esslonsCade,and my IFF . ` t
Ilmnse le In full forte end dfed. PANELS Y `+\
License Clam LIc.N
Date Contrador LIP TO 2DO AMPS
ARCHITECTS DECLARATION 201-1000 AMPS
p�'+mO X I understand my palm shall be used as public records. OVER 1000 AMPS ^SQ.Fr.FLOOR ANNNRR�!EA $/SQ.FT.
i4 (/ Licensed Professional SIGNS ELECTRICAL f l \� ll ®_ A'
OWNER-xempi ER DECLARATION SPECIAL CIRCUIT/MLSC ® D rs I��• '�v
gI" owing meaceemthaton 7031mplfromthe Contrad.re License Law dryer CL 1V/C!
po
following remon.(Semon 70.41 S,Buefneesand Profession.Code:An dryer AR!
OZF. Y tY TEMP.METER ORIOLE INS,. II�Q
r,S county which requlmrea permitbcorutmct,alter,Improve,demoibh,orrepalr Q
q' anyslmeture prlorto its Wuantt,alsomquimstheappllont femuch permit to POWER DEVICESATE
6 r0 file a signed amtereent that he b limned pursuant to the provlelores of the
Cruradoes License Law(Chapter 9(commencing with Section 7000)of Divi. SWIMMING POOL ELECTRIC
sion3 ofthe Business and Profmalmu Code)orthat he b exemptthecefromand VALUATION
0 the bash for the alleged aemptlon. Any vlulaUun a(Sectl. 7QI15 by any OUTLETS-SWITCHES-FIXTURES
no nt fora permit subjects theappOcant to a civil penalty olnmore than
Eve n. doll.n(f50S. NEW RESIDENTIAL ELECTR SQ.FI. STORIES TYPE CONSTRUCTION
�n I,aowner oI,he property,or my employees with wages a their sok
t pematlon,will do the work and the structure b not intended or offered for
5 0 Ie Sec.7044,B..I.and Pmfenloro Code:The Contractors License Law _
j$$ d s not apply to an owner of property who builds or improves themcm,and OCC.CROUP RFS.UNITS
C; who does such work himself or through hlsown employees,provided that such
improvements am not Intended or offered for sale.If,hcwevep the building or T91
improvement V sold within.neycarofcompletiogtheowner-builderwlll have
tfut burden of proving that he did not build or improve for purpose of sale.). QTy, PLUMBING PERMIT FEE FLOODIONE APN
El L as mvecr of the property,am exclusively contracting with Ilcenxd PERMIT ISSUANCEGamma es to mw(nict the project(Sec.7044,Business and Prvfenloru Code:
The Contnd.e.License Law time not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds .r Impmvee thereon, and who contracts for such pwjcds with a
�gpl��da(Q licensed pursuant to the Contrador'.License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B&P C for this reason
nl)TQFnP Peru
DRAINS FLOOR,ROOF,ARRA,COND. SANITARY Y N
. Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAX Y N
Of hereby affirm that I have o lm nate of consent d self-Insum,(S• RECEIPT N
3800,cedllab C.Workeri Compensal.n lraurance aracertllled copythereof Sec. GAS FA.SYSTEM-1 INCA OUTLET'S PARK FEE Y N
3$00,Leh CJ
Policy
"n an GAS PA.SYSTQd-OVER 4(EA) RECEIPT#
Y BUILDING DIVISION FEE
S
Certified copy is hercbytume ed.city CREASE/INDUSML WASTE INTERCEPTOR PLANCHECKPEE
❑Certlned copy V tiled with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' IGRRASETRAP PAID
COMPENSATION INSURANCE SEWER SANITARY STORM RA 20017 Date Revel t#
Trhiswdlonneednmbccomplet iftMpermitIsforonehundreddollen
($10o)orlsssJ WATER FTGTQ4 W/VENT/ELECTR ENERGY FEE Y N
I mrtlfy that N the performances ofthe work forwhich this permw
it le iaed, —
I shall not employ any person In any manner so es to become subjed to the WATER SYSTEM/TREATING PAID
-
Z
[.woof California. Date
O Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Recei t#
Z p NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
Fsh.ldbcc....b)ec[to the W.rkers'Comprecatl.n provisioruof the Labor TOTAL:
N Code,you..I forthwith comply Mthsuch powi l.ruorthb permtshall be
`_j deemed revoked. BUILDING FEE
W
CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z Iherebyafflrm that there%a construction lending agency for the perform. TOTAL. ELECTRIC FEE �•
arm of the work!or which this permit is issued(See.3097,Civ.Cd
fJ O Lander.Name PLUMBING FEE
IL Lred.e.Addrea CTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U Icertlfythatlhavernad this eppllatlon and datethatthe above lnfornutlon
O W lecorrect.I agree to comply with all city and county ordinances and state laws PERMITISSUANCE FEES PAID:
} 1 relating to building construction,and herebyauthorlurepresentattvesofthi.
F N city to enter upon the above,mentloned property for impaction purposes. ALTERORADDTOMECH.
? (We)agree to ave,indemnify an d keep harmiess the City of Cupertino Date Receipt#
V against liabilities,Judgments,cutuand expenses which may in anywayacerue AIR HANDLING UNIT CIO 10,(,10 CFM) SUBTOTAL'
against id Ityine.e quence.ft antingofthlspermn.
/ NR FIANDLING UNIT(OVER 10,000CFM) CONSTRUCTIONTAX
Signmera of Applicael,fContractcur Dae EXHAUST HOOD(W/DUCT, CONSTRUCTION TAX PAID:
HAfA R DOUS MATERIALS DI SCLOSURE
Will the applicant or future building onvpact store or ba ad Is havardous HEATING UNIT(TO 100,000 BTU)
nvatada l as de0md by the Cupertino Me nicipal Code,Chapter 9.12,and the Date RecelI#
Health and S fey Cade Section 2$32(.)7 HEATING UNIT(OVER 100,000 HELD TOTA
❑Yes r!No
Will the applicant or future be llding occupant use equipment or d scions VENTILATION PAN SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
• QX.lily Management Dlstrict7 BOILER-COMP(3FN OR 100,000 BTU) PAID
Yes No m
have read the hazard rterials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the Califomla health&Safety Code,Sed Ions 25505,25533 and 25534.1 �� ��, 1991
understand that if the building does not currently have a tenant,that it is my NEWRESIDFNTIALMECH, SQ.Fr.
responsibility to notify the occupant of the requirements which must be met
prior to hesea nor of a Certificate of Occupancy.
CU r..e.r.UI�N I u
Owner or auth.tlmd agent Date
TOTAL: 11
ISSUED BY:
OFFICE COPY