23660 APPLICANT TO FILL IN INFORMATION WITHIN-RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PERMITNO.
Building Address:
23660 . .
i-ovo .
sere ante: e: p A
CITY OF CUPERTINO-BUILDING DIVISION �`1 ���
c isms o .Name: No APPLICATION / PERMIT 1
V BUILDING-ELECTRICA MP BING-MECHANICAL LATE-GORY CONTROL It
Archftect/Engineer: Lic.No:
1 i•' r:;`re$UILDING PERMITINFO+� '',; 4
4'fY. , +� E•ECTRIC PERMIT i;:FEE
AddressO PERMITISSUANCE - ❑ ❑ 1:1LICENSED CONTRACTOR'S DGCLARAiION
I hereby affirm that l am licensed under provisions of Chapmr9(consomme APPLIANCES-RESIDENTIAL J BD ON
ingwith5ec OA7000)of Dlvision3ofthe Busin sand Professions Code,and my
license Is In ful fo and effect „ PANELS L
'License last CLie.r 2 9 h
Date Contactor /I__
ARCHITECTS DECLARATION 201-1000 AMPS sG ll
N CO I understand my plaru shall be used as public record.. OVER 1000 AMPS SQ.PT. •i R AREA SQ.ET.
(/ Licensed Professional SIGNS ELECTRICAL -
6 w OWNER-BUILDER DECLARATION
I`n I"n SPECIAL CIRCUIT/MLSC p^`'
X02❑ owing a(m.(Sethat lamexem fromsa d Pronfctorb License Law A.ydtthe a r, ® I' V
Z F H� following reason.(Section 7Bftto Business and,,i np e, Code:Any cep or TEMP,METER ORPOLE INST. �”'
r countywhich requiresapertNttoconstmct,alter improve,demoWh,orrepalr \ ^�. '
gg'� Q ale
prlorto its Issuance,also requirestheappllcent forsuch permit to POWER DEVICES (�./ i P T f • �.�[
k3'� U ale a signed statement that he is licensed pursuant to the provatlom of the (�,o I l -
W6W6 O y, Contractor's License Law(Chapter 9(commencing with Section 7000)of Dlvl- +
�0!`m SWIMMING POOL ELECTRIC I
a slon3oflhe euslnevand Profevlons Code)orthatheis exemp[therefromand - �`•' i AFIATION
.a the basis for the alleged exemption. Any violation of Section 7031.5 by any OUILEISSWITC7{ESHXTURES O �•�
GoS appllcantfare permit subjects the applicant to a civil penalty of not more than
flue 1,as o nerdidof the pr. NEW RESIDENTIAL ELECTR SQ.ET, STORIES TYPE CONSTRUCTION
SSWWff �n ❑I,as owner of the property,or my employees with wages as their Bole
mon
pensation,willdothe work andthe structure at not intended or offered for
q sale(Sec.7044,Business and Prifesdom Code:The Contractors License law
$ does not apply to an owner of property who halide or improves thereon,and OCC.GROUP RIS.UMTS
EEE who doessuchworkhimselforthmugh hisownemployees,provided thatsuch
Improvement are not Intended orof&wd foraale.R,however,thebuilding or TOTAL:
Improvemonttsold withinoneyearofcomplelion,the owner-builderwill have
tlrden of proving that he did not build or improve for purpose of sale.). PLt;11bMB(NG PERMIT „FEfi(:'.' ETADD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCEcontractdre to construct the project(Sec.7044,Business and Profession Code: .�
TheContmctere License Law does nae apply to an owner of property who )
buil or Improve.thereon, and who contractsfor such project with a ALTER-DRAIN&VENT-WATER(EA
c,}tLLIjIactor(.)licensed pursuant m the Conmidor'e License Law. BACK FLOW rROTPLT DEVICE FEESl1M�•1iARY
LJ I am exempt under See. B&P C for this reason
Owner DRAINS FLOOR ROOF,AREA,CON I. SANITARY - Y N
.� Date RFAl71' p
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP - SCI{OOL TAX Y N
F11 hereby affirm that I have'.certificate of consent to self-Insure,ora ��,p
certlflcete of Workem'CompensaHonlnsurance ora certified copythereof(Sec. GAS EA.SYS'T'EM-1 INCAOUTLETS PARK FEE Y N
3800,lab C) rs //�3 rl r� (y 1�
Polity R RECEIPT k
GAS EA.SYSTEM-OVER 4(EA)
Com any Ish rn fA BUILDING DIV]SION FEES
Certified copy at herebyth the city CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certlaed copy t(fled with the tlty Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE gEwFR-SANETARY-STORM EA.2001717. Date Remi t#
(Thlssection need not be completed if the permit at forces hundred dollars
• ($100)or lav) - WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I comlythat in the performance of the work for which Ws permit is issued, —
I shall not employ any person In any runner so m to linemen subject to the
-Workern'Compareation Law.of California.Date WATER SYSTEM/TREATINGPAID
O Z Applicant
Z O NOTICETO APPLICANIM If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB, SQk T. Date ReC f tN
Fshould become subject to the Worker.'Compensation provisions of the Labor TOTAL:
N Code,you mus:forthwith comply wahsuch provisions or this permit shall be - -
> deemed revoked. BUILDING FEE
W CONSTRUCTION LENDING AGENCY - SEISMIC FEE
CL Ihereby affirmthat there at a construction lcndingsgenyfor the perform- ^ m ELECTRICFEE
7 Z ♦ ante ofthe work for which that permit at Issued(Sec.3097,Civ.C.) - TOTAL l J`�
V'O 'Lender.Name - - + PLUMBING FEE
IL F LeadersAddrcm QTY: " MES ANICAL PEBr'tIT a2FEE MECHANICAL FEE
O W Icertl(ythat]have readthatapplimtionand slatethatthe above lnlorrtution
fl is correct.Iagreeturcmply with all cityand county ordinances and state laws PERMTTISSUANCE FEES PAID:
} rel a ting tobullding comtsuctlon,and hereby authorlu representative.of this
Zcity to enterupon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
(We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
V against lUblllties,judgment,met...du.penses which may in anywayaccrus AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL
against said City in consequence of the granting of this permit.
AIR HANDLING UNIT(ov17R te,lne clm4) ' CONSTRUCTION TAX
Signature of Applicant/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZAR DOES MATERIALS DISCLOSURE
Willtheappllcent or future building occupant store or handle hacardous HEATING UNIT(TO 100,000 BTU) Date ReCei t
material as defined by the Cupertino Municipal Code,Chapter 912,and the
Health and Safety Cade Section 25532(a)7 [BEATING UNIT(OVER 100,000 BTU) TOTA
1,1
❑ Yea INo
Will the applicant of htture building ompant use equipment or devices' VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air ,
•� I,lty Management District? BOILER-COMP OHP OR 100,000 BTU)
4 Yoe qu. p
have read the hazaus materials requirement W a'Y
under Chapter 6.95 of BOILER-COMP BTU) 9" 1•1)
the California Health&Safety Code,Sections 2550.5,25533 and 25534.I -
understandthatifthebuildingdoesnotcurrentlyhave.tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. �Rq��
pme oor
to sol RCartih pant of the requirement which must I„n ,1aa��
prior to Luudpce ofd CertificFJe mi anry. y
(I.J7l.P1IrJV7h®/'l A- ST f 4=171 a� C!]-Y ur
Owneror uthorized agent Date ISSUED BY:-t\ ¢�(JR-`trfy
' ' TOTAL:
OFFICE COPY