23746 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildin Pr.1.0 Identification PERMIT NO.
Building Address: 23746
(:c1D70 ���� ow Piece
Mrnare: ) one' A A A
.57C uer75 /n Prrf/t 9�H-n�.�Ct CITY OF CUPERTINOBUILDING DIVISION r�
onrattor'e Na pn Lt.Na: APPLICATION I PERMIT J a?,
11 BUILDINC-ELBCTRICAI PLUMBINC-MECHANICAL CATEGORY CONTROL p
Archimet/Engineer, s� Llc.No:
ELECTRIC PERMII';x~ i"�li =FEE BUILDING.PERMIT
tINFO
a,tctltA yl i.":. :
Address: PERhIITISSUANCE 1:1 ❑ El
CONTRACTORSDECLARATION
thereby
afTumthat lam Vcmud under pravWone of Chapter9(mmmrnc- APPI.IANCESRESIDENTIAL )OB DCSCRR'I ION
ingwith SeMon7000)of Division3 ofthe Businessand PmfessionsCade,and my
limnre Is in full form and affect. PANELS
License Class Lt.M
Date Contractor UP TO 200 AMPS �76/a/6�r
ARCHITECT'S DECLARATION 12014000 AMT'S
X Z I understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FE.
VP
JO Licenwd Professional SIGNS ELECTRICAL
%co OWNER-BUILDER DECLARATION
3 IherebyafRrmthatlamexempt ImmtheCxd.dm.Llrense lawfor the SPECIAL CIRCUIT/MIST
following reason.(Section 70315,Business and Professions Code:Any city or TEMP.METER OR POLE INST.
county which requires a permit to construct,alter,Inprov4 demolish,or repair
.s anyetmeture prior to its Issuance,also requires the appVant forsuch permit to POWER DEVICES
5: Rk a signed statement that M Is Bmnsed pursuant to the provisions of the
Contractors License Law(Chxpmr9(commencing with Section 7000)of Dlvl- SWIMMING POOL ELECTRIC n5 VALUATION s3on 3 of the Business and Professions Code)orthat he Is exempt therefrom and
the basis for the alleged exemption. My violation of Section 70315 by any OUTLETS-SWITCHES-FIXTURES /� Q
applicant for a permit aubirm,the applicant to a civil penalty of not more than \/
Eve undred dollus($500. NEW RESIDENTIAL ELECTRSQFr. STORIES TYPE CONSTRUCTION
u owner of the property,or my employees with wages as their sole
m peruadon,wWdothework,and thertructure is not intended or offered for
y O sale(Sec 704y Business aM Pnafesloru Code:The Contrattals Limrue Taw
$� does not apply to an owner of property who builds or improves thereon,and OCC.GROUT' RFS,UNITS
who devasuch work himself or through hisown employees,provided that such
Improvements are not intended or offered for sale.If,however,the building or TOTAL:
Improvement is sold within one yearfcompleti. ,the owner-buRderwill have .ex,,. ,,,,,_„_, _,.„4,„,.,,,• �,,,,„,_ -,,,
llp*rden of proving that he did notbiddurim rovefor wofsele.). ' S- !' r'
L as owner of the property, P Pure° OIY: v xa:`-# PLUMBING`PERMIT:is c";`.'tY' !P FEErj FLOOD ZONE APN
p perry,am exclusively contracting with Ilmnsad PERMITISSUANCE
The Contrato constructieeme L w o does
70Kapply
Business and of fusion Code:
The Coor improves
es rhes Law aces mat apply is i owner of property who ALTER DRAIN&VENT WATER(EA)
WBede or improve thereon, and who mMntta toe each piojetts with a t .c�.tA'AClsscrt2IFEE:SUMMARYy W,
LjIam exempt undePursr
Sntro the Contractors License Law. BACK FLOW PROTECT.DEVICE ) '•"'"� "- I tI s,
I am exempt under See. B&P C for this reasonru
Owner Data DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N_
RECEBT a
WOR KMAN COMPENSATION❑ DECLARATION
re,ora FLXITCRFS PER TRAP SCHOOL TAX Y N I hereby aHlrm that I have a arHfiate of convent ro aeV-Inw
Certificate afWorkea'Comperwtion Insuranm or a artRFLEB'f XiHed copy thereof(Sec.
3800,lab C.) GAS F.A.SYSTEM-1INCA OUTLETS PARK FFE Y N
Policy a RECEIVE N
Com an - GAS EA.SYSEEM-OVER4(EAI
Y e BUILDING DIVISION FEES
CerHRed copy is hereby furnished.acity
Certified copy Is filed with the city Inspection division. GREASE TR USIRL WAS1E IN'1'ERCEI'IDR �� !I LA CHECK FEE ry
t”[
CERTIFlGMPE COMPENSATION
NS FROM WORKERS' GREASE TRAP P AI
COMPENSATIONWSURANCE SEWERSANETARYSTORM EA:2' — Date Recei W
(Chis section need not b completed V the permit Is for one hundred dollars
(Slmlorless.) WATER FIFA W�VEM/ELECTR NE GYFEE Y N
Imrtlfythat N the performance ofthe work forwhich this permit Is Issued, _ —
I shall not employ any person N any manner w a+to become subject to the IyA.pEg y57FM/TREATING _
Workerx Compensation LawsofCalifomia.Date PAID
Z r Applicant NEW RESIDENTIAL PIMB. SQ,Fr. Date Recei t#
O ` NOTTCEco APPLICANT.eWo,rmakinglhb Certificate of Exemption,you
shouldbecome subject tothe ply with
Cuch prwHonprovIslmomfthe Labor TOTAL:
N
Code,ordr =a.forthwith comply with such provisions orthIs permit shall be BUILDING> deenRd revoked.
G CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hembyaffirenthat there is.communion kodingagency for the perform, TOTAL: ELECTRIC FEE
O ance of the work for which this permit is issued(See.3097,Civ.C.)
Lendar.Name i„ r PLUMBING FEE
b- [.enders Address Q7Y' �.;�..'hIECFIANICAL;PERMIT xc; r FEE.�� MECHANICAL FEE
O ImrtifythatThavereadthisappBoHonandstatethattheabovelnformati n
W ommod.I agomto comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
Nrelating to building construction,and hereby authorise representatives of this
Z city to enter upon the above-mentioned property for Inspection purpose. ALTER OR ADD TO MECH. t#Date Reeei
(We)agree to save,Indemnify an d keep harmless the City of Cu Perim p
against liabilities,judgments,mats and expenses which may in anyway serous AIR HANDLING UNIT(to 10,000 CFM) SUBTOTAL:
against said City Is consequence of the grant ug o(.hk permit AIR HA NDLING UNIT(OVER 10,010 CFM) CONSTRUCTIONTAX
si oamre of pplanvcamrattar Dat EXHAusT Hoop(w/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building rampant store or handle hazadous HEATING UNIT 00100,000 BTU) Date Recei
material ac defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(.)7 HEATING UNIT(OVER IDQ000 BM TOT
r-] Yes M No
Villtheappiiant or future building occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
�Ih emit havardous air contaminants as deBnd by the Bay Area Air
r Ity Management DIstrici2 BOILER-COMP OHP OR 100,003 BTU)
Yes No
have read the h.19mmateriala requirements underChapter6.95of BOILER-COMP(OVER100,000 BTU) N �
the California Health&Safety Code,Sections 25505,25533 and 2S5N. I
understand that lithe building does not currently have a tenant,that it is my NEWRESIDENTIALMECH. SQ.FT.
responsibility to notify the occupant of the requirements which must be reset f!A`/,v ry
prior to Issuance of a Certificate of Occupancy. rlx9' j
r ,
Owner or awhorixd agent Date
TOTAL: ISSUED I I�cvF
OFFICE COPY