23862 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN•ONLY
Building Project Identification 7 PERMIT NO.
Building Address: 2.3862 VS^8^ n
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�� ,_ SeL �Ji�p2 CITY OF CUPERTINO-BUILDING DIVISION D
C naa rXName: n: APPLICATION / PERMIT
ogm �`e"^' BUILDINC-ELECTRICALPLUMBING-MECH LAICAL CATEGORY CONTROLX
Architect/Engineer. LIc.No:
I BUILDING PERMIT INFO
I QrY ELECTRIC PERMIT FEE
Address: PERMITISSUANCE ❑ ELECI 77T
1:1 ❑I LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commenc- APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwlth Se on7000)ofDiWslon3ofthe Buslnemand ProfessionsCode,and my
licenseimn-iGIaLieffect PANELS /�1• ^ -F'' a a
Ls4: e.X__ oa 47.J - ✓ , IL.J U I
UP TO 2DO ANTS
Date Contract A/ /M/7(A.Kj
ARCHITECTS DECLARATION 201-10DOA.MPS
OZ I understand my plamshall be used u publicrecords. OVERIOOOAMPS SQ.Fr.FLOOR AREA E/SQ.FT.
COC
Licensed Proteaslorai SIGNSELECTRICAL (' 1�
G<W OWNER-B UILDER DECLARATION
SPECIAL CIRCUIT/MISC
I'gj.7i owingfhemagora.(hat l am 31-5,B fromthe d Pro ctor.Ll ode:law(orthe
Zp p following reason.(SMIon 7031 S,Business and Pmtenlons Code:Mytlty or ^1
OZF'W cauntywhi6requiresaper ttommtmdalter,impmvgdennlbh,orrepalr �P.METER OR POLE INST.
qF`��Cai anystmo mprlortoitsissuame,aLsorequimsiheapplicantforsuchper tto -71Z771,z
E file a signed statement that he(.licensed pursuant to the provisions of the POWER DEVICES
3wG Contractor.License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
F,E,O� go.3ofthe Business and Profc®Ions Code)or that he is exempt therelromand VALVA
the basis for the alleged exemption. Any vlalafion'of Section 7MIS by any
<5 OU-METS-SWITCHES-FIXTURES 5�O -
applicant fora permit subjects the applicant to a civil penalty of more than a
five 1,as owmrofthed dollars e pro NEW RESIDENTIAL ELECTR FT.
i7 Q �1,as owmr of the property,or my employees with wages there sale —SQ.FT. TYPE CONSTRUCTION
compensation,will do Business
work cession structure E not Intended or?offered for
� ❑
sale(See.apply
to
oanow and Professions Code:builds or
or improves
License law
�5$
who does
apply loanowner ofproperty
rough whonemporTmproovidedreoRand - OCC.GROUP RES.UNITS
nu aorkMmaellorthroffe his own le.if oweprovidedthatsuch
improvementsamnot Intendedvarofe forsale.I(,h nes-Wilder illi ve TOTAL
' 4nprovemenHswld withinone)narofcomplelbn,theowner-bullderwlll love
t rden of proving that he did not build or Improve for purpose olsale.). QTY. PLUMBINGPERMIT FEE IOD ZONE APN
LBO
I,as owner of the property,am exclusively contracting with licensed ISSUANCE
contractors to mnstroct the project(Sec.70K Business and Prolesslons Code:
The Contractor's License law does not apply to an owner of property who ALTER DRAIN&VENT. WATER(EN
Wilds or Improves thereon,and who contracts for such p,*u with a FEE SUMMARY
cgR((ador(s)limned pursuant to the Contractor's LlmnrLaw. BACK FLOW PROTECT.DEVICE
LI I am exempt under Sec. B&P C for this reason
Owner Date DRAINS.FLOOR,ROOF,AREA,COND. SANITARY Y N_
�--s WORKMAN COMPENSATION DERECEIPT X
CLARATION
ISP hereby affimr that I have a certificate of consent to self-Insure,ora FIXIlJREv'PER TRAP SCIYOOL TAX RECEIPT X
certificate of Worken'Coripevatlon Insurance ora certified mpythereof(Sec.
3800,lab C3' GAS EA.SYSTEM-I INCA OUD,ETS PARK FEE
/ Fxuitcys 1a.9333i9-9.1 RECEIPT XcAs rA.srsTEM-cave.. EA)
Com y DT BUILDING DIVISION FEES
c Bed copy ishrmbyhamishad. caFAse/INousrRLwnsTELNTERCEPTOR PLANCHECKFEE
-+ ertified copy b filed with the city Inspection division.
CERTIFTCATEOFEXEMPTIONFROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCESEWER-SANITARY-STORM EA.200FT. Date RC i t#
(This section need not be completed 11 the permit is for one hundred dollars
($100)orlem.) - WATER HFATER W/VENT/ELECTR50. ENE'RGYFEE Y N
I certify that in the perlorrtanceof the work forwhlch tNs pemnb b?.sued,
1 shall not employ any person In any manner m u to become subject to the WATLR S STEM/TRFATLNG
z
Workers'Compensation laws of California.Date PAID
-
z
Applicant NEWRESIDENTfALPLMB. SQIT. Date Recei t#
Z NOTICETO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensatlon provisions of the Labor TOTAL:
CC W Code,you most forthwith comply with such provbiom orthb permit shall be BUILDING E
W > deemed revoked. ,
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d I hereby affirm that there Is a construction lending agency for the perform- TOTAL: ,� ELECTRIC FEE
Z arse,of the work for which thin permit B unued(Sec.3097,Cl,C.)
U O Tenders Name - PLUMBING FEELL d
F Lendcr's Address QTY. MECHANICAL PERMIT FEE
O W Imeifythaflhavemadthisappucattonand state that the above information MECHANICAL FEE
iscorma.l agree to comply with all city and county ordinances and state laws PERMRLSSUANCE FEES PAID:
} N relating to building construction,and hcreleyauthorimmpresenfafiveaofthts
I— city to enter upon the above-mentioned property for Inspection purposes. ALTER ORADDTO MECH.
(we)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
V 'a gairstliabilities,Pdgments,costs and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: 0
.gal Ci y in conscryenre he i ting of this pe it.
�� „4 ti AIRHANDLINGUNIT(OVER IO,000CFM) CONSTRUCTION TAX
Sign ore of Applicantd ontracfor(� Date EXHAUSTHOOD(w/DUCO - CONSTRUCTION TAX PAID:
HA RDOUS MATERIALS DISCLOSURE
Will theapplicam or future building occvpart store or handle havardous HEATING UNIT(TO I(D,000 BTU) Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the
Flezlthand Safety Code Section 25533(.)? BEATING UNIT(OVER 100,000 BTU) TOTAL: (/
❑Yes MN.
Will the a ppiim rat or future bis ilding occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit usaardous air conts mimnts as dented by the Bay Area Air
Quality Management District? BOILER-COMP OHP OR IW,=BTU) p
4Yes �I NO P A I p
have ad the h mous materials requirements under Chapter 6.95 of BOILER-COMP(OVERIW,O O BTU)
the California health&Safety Code,Sections 25505,25533 and 75536. I- 1 �(� .X(((��Y
understand that nthe fy the occupant of
not a requiyhave s tenant,that it be is N'EW AESIDFNIIAL METH. `-'Q ET JUN
responsibility to notify the omupant of the requirements which must be rrcM 92
prior to issuance of a Certificate of Occupancy.
Owner or authorlud agent Data ISSUED BY.
` s.f1IlIYV
TOTAL:
OFFICE COPY