21573Ie
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Idrndfk,tim B Fz t
,� � 9
Building Address:d
PExwr21 7 3
'5
n Phare
racteis amt: I ;TAULLk.Na:
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUfLDINGELECTRICALPLUMBINGMECHANICAL
CATEGORY
CONTROL a
/Fs ver LIG No:
QIY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Addns
❑ {�j ❑ ❑
q�
PERMITIS5UANCE .2 W
LICENSED CONTRACTOR'S DECLARATION
L�7
Ihembydfirmthatlamlkma uMerprovL.Torso(Chapter9(mnmenc
- APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
PANELS
ingwith Sectlon 7000)of D(Weim3ofthe Bualnassard Profen Cnds d my
I but
ice e. I
Dam Contractor
DamCon
000M
ARCHITECTS DECLARATION
OVER
OVER 100000 AMPS -
SQ. FT. FLOOR AREA
5/9Q. FT.
Iunde�and my plan.haB be errenpubllc records
SIGNS ELECTRICAL
LI¢r sed Professional
'
9WJALCIRCUIT/M1S
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Comnctor'a Limn: law fce the
TEhIP, MCIFR OR POLE INSP.
following reason.(Section 70315, Busmen and Prof®Ions Cade: Any city or
countywhich requimeta permit tomvtroct, alter, Improve, dernolbh,or repair
anyanucture pAmto its issuance, also requires the appllont for such permit to
file • signed statement that he Is licensed pursuant to the iuo tcv of the
POWER DEVICES
SWIMMING IDOL ELECTRIC
2 OUTLETSSWITCI IESHXIVRES
Contractor's License Law (Chapter 9(comnnrctng with Section 7000) of DWI-
elon3 of the Business and Profenlov Code) orthat he 6 exempt therefromand
the basis for the alleged exemption. Any violation of Section 70015 by any
lty of not room than
Ht. the applicant to • vll penalty m
applicant for a permit d
VALUATION
NEW
NEW RESIDENTIAL FT.ECIR SQ �.
Oundred dollars 1OW.na6n ee
I, owner of the property, or my employwith wages a theIr solo
TYPE CONSTRUCTION
mmpere ation, will do the wer"nd the Yroctu re 6 ort intended or offered for
ssle (SeG 70µ Busmeas a Pmfesslov Code: The Comractor', License law
doe not apply to an owner of property who bulli. or improve thereon and
who does .6 work himself or through his own employee, provded that such
Improvemonm ane not Intended orotfered (m sok. It, however, the bWli ing m
TOTAL:
OCC.GROUP
RFS UNITS
Improv r m6,al hinorcyearofc pldtb theavner-WBdnwBlhave
QTY. PLUMBING PERMIT FEE
thg,jxmden of proving that he did rot build or Improve for purpose of sale.).
LI L as owner of the property, no erdwively mntncting with licensed
mrtruton tomMru¢the project icer -70N, &alnu,rd Rderbn Code:
HOOD TONE
APN
PERMIT ISSUANCE
The Contractor's License Law does not apply to an owner of property who
builds or Improve thereon, and who contracts for such p(ojects with •
.X(T.cton(.) hewed pursuant to the Contractor's License Law.
L� I ,m exempt under Sm B & P C for this reasonOUTSI
ALTER -DRAIN Is VEM-WATER (PA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DE FEES
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y N_
RECEIPT s
Owner Drte
WORKMAN COMPENSATION DECLARATION
❑I hereby dfirm that I have • ceniflate of conrnt to .9 -insure, or
¢nifiateofWorken'CompenaaEa�Insunnce¢a certyledmpythereof(Sec.
lab CJ
1tlkyl Mf
kLJKC Ifiedcopyisherebyfum6hed.
Zedl copy 6 filed with the city inspection division,
FIXTURE"' PER TRAP
SMOOL TAX Y N_
RECEfiT g
GASG SYSIEM-I INC{OUIM
PARK FEE Y N
RECERTs
GA . SYSMOVE4(EA)
BUILDING DIVISION FEES
GREASE/INWSIRL WASTE INrmcQ'TOR
PLANCHECKFEE
GRFASETRAP
CERTIFICkn OF EXEMPTION FROM WORKERS'
PAID
COMPENSATION INSURANCE
(I'hissMbn need not be e"Ided lithe permit 6 fa ons hundred do0ara
SEWER-gANITARY STORM FA 200Ff.
Date Retxi I#
WATER HEATER w/VENT/FTFCTR
ENERGY FEE Y N
,
Cs1om«lea.)
I¢rtBy thrtbthe perforrtan¢of the work for which thus pemdt6beaeQ
WATER SYSFEM/TTZEATTNG'
I shall not employ any person in any manner n as to become subject ro the
W¢kers'Compensationlawsof C.lRon6. Date
PAID
NEW RESIDENTIAL PLMB. SQFC.
Appuant
NOTICE TO APPLICANT: If, &fist making this CertBlcate of Exemption, you
should become subject to the Wohen'Compereatbn provisions of the Labor
Date Recei t#
TOTAL
BUILDING
Cade, you need forthwith comply with such provislov orth6 permit shall be
deemed mwoked.
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I herebyaffirmthat them 6 a cov6u11on lendingagenRy forthe perform-
an¢ of the work for which this permit is Issued 309], CW. CJ
leder. Name
L<ndere Add res
I cart ify that l have red this application a d bate that the above information
Is correct. I agree to comply with all dty,nd county edNanmand state laws
TOTAL
FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT LSUANCE
FEES PAID:
relating to building construction, and hereby authorlre mpnaentativca of this
cXy to enter uponthe abovo-mendovd property for Wpeelnn PUTp
(we) agree to save, IdemNfy an d keep harmless the City of Cu port W
ag. t bwttes,ya ma,m a expeveswhichmayln,ryway.mue
ALTER OR ADD TO MPOH.
Date Recci t#
AIR HANDU NG UNIT (TO 10,000 CFM)
SUBTOTAL:
ago t d Nyin n of ml gathis ermit.
n +
AIRHANDUNGUNTT(OVER lo,owcFM),
CONSTRUCTION TAX
m fAp est t Date
DmAll5r HOOD(W/DDCD
CONSTRUCTION TAX PAID:
N RDOUSMATERIALS DISCLOSURE
HEATING UNIT(1O100,000BTU)
Date Reeei t#
eapp0ant future buBding oavpnt Wore or hadkhawdoua
mte
arialasdefined bythe Cupertim MuMdpal Coda Chapter9.17,,nithe
Healt Ynnd Safety Code Section 2S537(a)7
No
qllltheapplloMorf WmbulldNgo pantuseequipr mordevkn
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN($WGIE IffSID)
ISSUANCE DATE
which eMt)umndoa. ala contambantsas defined by the Bay Area Ab
Quality Management District?
4Yca FF�� No
havemad the haraR• materials requirements under Chapter &95 of
the California Health & SafetyCode, Sections 25505,25533 and 25534. I
understand that if thebu Oding doe not currently have a tenan4 that It Is my
A,�
Tt'�.I'
AM
goes eo-COMP DHP OR IOQIXU BTU)
IIOII.FyCOMP(OM m,000BTU)
-
NEW R111DFNfIAL MECH. SQFf
responsibility to notify the occupant c(the requiremems which must be met
prior to issuance of a Certificate of Occupa ney.
ritV 1 Iwo
I dtI1A
va7V
Owner or avthorird agent Date
TOTAL:
OFFICE COPY