23736APPLICANT TO FILL IN INFORMATION WITHIN RED LINES.— USE BALL POINT PEN ONLY
Building Project Identification
Building Address:
PERMIT NO.
N-23736
D� Z
nes : - ansaAPPEICA,
CITY OF CUPERTINO-BUILDING DIVISION��2�1y�
APPLICATION (PERMIT
NON RuNhill JAL
on • LIC No -
12 - arlBUILDING¢ECTRICALMUMBING-MECHANICAL
CATEGORY
CONTROL M
Archils Engineer. Lk No:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Add.
tt ❑ ❑
PERMIT ISSUANCEEl
LICENSED CONTRACTOR'S DECLARATION
I hereby dOimnthat lam Bon3ofthe under provisions ndPmfe smsr9(commena
Ingwith5ecti.n7000)of Dlvielon3o(the Buelruaand Profesel.ne Code, and my
license i In full o d dfed.
LlcenseC a Llc.p ��.
APPIlANCFSRESIDENTIAL
JOB DESCRIPTION
PANELS
Date Contra cior_tJ200
ANTS
201-1000 AMPS
ARCHITECTS DECLARATION
I understand my plans shall be used a public record&
OVERIODOAMPS
SQ. Fr. FLOOR AREA
S/SQ.Fr.
SIGNS ELECTRICAL
Licensed Professional
SPECIALCIRCUIT/MISC 4`3 JLAA
OWNER -BUILDER DECLARATION
I herebyaflirm that I am exempt (romthe Contradues License law for Poe
7FMP.MEfTA OR POLE INST.
following resson.(Seellon 7031.5, Business and Professions Code: Any city or
counlywhlchmqulresapert ttomatmd,oteq Improve,demolish,orrepair
'
anyswdurc prforto lb lasuarice, also requlrn theappBam(w such permitto
file •signed statement that he is licensed punuam to the prov ste. of the
Contractors License Law (Chapter 9(commencing with Section 70M) of Divi.
ofthe Business and Professions Code) or that he Is exempt there(romarW
WE.RDEVICES
yyy ANG POOL ELECTRICsion3
VALUATION
the basis for the alleged exemption. Any violation of Section 7m15 by any
applicant for a permit subjectstheappllcant to a civil penalty d not room thin
OUTLETSSWITCHFSFlKIURFS
NEW RESIDENTIAL ELECTR SQ.Ff.
flue hundred dollars .
F owner of theheproperty, or my employees with wag" a thele sok
STORIES
TYPE CONSTRUCTION
compensation, will wokand the tlmcW offered
Ttootntracted.r
sale (Sec. Business and
alnow and Proteslons Code The License Law
w
—r.�a
` J
to
dos nottosuch loan owner ofproperty whohism Aem orimproovided thereon, and
apply or impown
o a,provhiedilding or that such
who doementsa son Intelfedorough hlsowne. If,however,
Improvement arenotintended e.,.fred pletion,the ow er-bul ierwill have
Improverrcnt twld withinoneycar.(complcibn,theowner-bu0derwill have
OCC. GROUP
RFS UNITS
tlg;karden of proving that he did not build or improve for purpose of sale.).
u L as owner of the property, am exclusively contracting with licensed
contractor toeoomet the prayed (Sec. 7044, Buslnea a MPro(eul�rCgd
The Contrectorb License Lw dcea nd apply t0 an owner d profjry- ajh
Wilds or Improves thereon, and who contracts (a such in je•d wit
,➢tt[+et eW li amed pursuant to the Contractor'• Llmnse Law.
1_J I am exempt under Sec. B 4 P C (or t n
PLUMBING PERMIT FEE
QTY,
PERMIT ISSUANCE
L a Bass'
(FA)
FLOOD ZONE
APN
FEE SUMMARY
W '
D S OND.
SANITARY -— N_ '
RECEIPT
Owner Dat
WORKMAN COMPENSATION DECLARATION DA
1 hemby affirm that I have • rertiflute of consent t° 1( -Insure, ora
o flats of Wen keri Compduationlasuranrnoamrtl(ied
E
N
SCHOOLTAX Y_ N_
RECEIPT N
GAS FA. SYSTEMS WG40UTLEI5
PARK FEE Y N
co�ythsent(5°c.
3800, Tab C.)
Policy Y
RFGEPT M
GAS M. SYSTEMAVCR4 (FAJ
Com any
BUILDING DIVISION FEES
DuCertl(led copy is hereby te cid.
xriTCertlOed copy t filed withh the city IapecH°n division.W
GREASEANDUSIRL WASTE INTERCEPTOR
PLANCHECICFEE
GREASE TAN'
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
COMPENSATION INSURANCE -
Cfhtsect(.n need nal he complded if the peoNt t (ororu hundred dollars
($10(ilmless.)
I rertffythat in the performance of thework for which this permit is issued,
I shall not employ any person It any manner so as to become subject to the
W°rkers'Comformation Laws of California. Date
SEWERSANITARYSIORM F.A.MIT
Date Re i tN
WATER HEATER W/VENT/¢EGTA
ENERGY FEE Y N
PAID .
WATER SYSTEM/TREAl7NG
'Applicant
NOTICETO APPLICANT: If, after nuking this Certifiam cd Exemption, you
should become subject to the WorkersCompensation provisions of the Labor
Date Recei0tg
NEW RESIDENTIAL PLMB. SQ.Fr.
TOTAL:
Code, you =at fort moth comply with such provisions or thin permit shall be
deemed revoked.
U DI NG FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
Iherebya(Onn that there Is a construction lend Ing agency for the pedorrry
ance of the work for which this permit t tsuadl Sec. 3097, Civ. C.)
Lander'. Name
Lender'.Addreaa
I certify that I M1ave read this application and mate that the above information
incorrect. lagreeto c.mplywlth all cityand countyoNtanres and sUtelawa
relating to building construction, and hereby authomem representatives .f this
city to enter upon the abovecrantboed property for Inspection purposes.
(We) agree to save, Indemnify an d keep harmins the City of Cupertino
TOTAL:
ELECTRIC F E E l
EEE
L
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
Date Recel lap
ALTER OR ADD TO MECH.
- SUBTOTAL:
against liabilities, judgments, con.and expen.n which may In anywayamuo
against said City In consequence of the Branding of this permit.
AIR HANDLING UNIT ITO 10,000 CFM)
AIR HANDR
LING UNIT lO,000CFM)
CONSTRUCTION TAX
Signature of Applicant/Contractor Data
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
-
Will the applicant orfuture building occupanbtore or hand Is haaardous
material as defined by the Cupertino Municipal Code, Chapter9.12, and the
Date Receltk
HEATING UNIT(OVER 100,000 BTU)
TO %
Ifealth and Safety Code�--Srrection 25532(x)?
❑ Y. No
VENTILATION PAN (SINGLE RESID)
ISSUANCE DATE
Will the applicant or future building occupant use equipment or devices
which emit haurd... air contaminant as defined by the Bay Area Air
Quality Maragemcnt District?
4Ya No
havereadthehazardousmaterialsrequirementunderChapter6.9"o of
the Ca lifomt Jlaxalth&Safety Code, Sections 25505, 25533 and 25534. 1
PAID
�AY27
BOILER -COMP OHPOR 100,(10) BTU)
BOILER -COMP (OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ.FT.
understa Hf the building does not cur ly have a tenant, that It t my
resp. Blty to notify the occupan,. airmen which must be met
prim uance daCertlll leof pancy.
qn
IJ
CITY
Owner Or od nes ate;���y�a
'
�/{�y
ISSUED BY: V Va/� Yy i
TOTAL:
OFFICE COPY