23985 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PERMIT NO.
ding Addmu: ` 23985
7& 1ansae am
.TmE< <!NY 996-9d'7e9 CITY OF CUPERTINO-BUILDING DIVISION
Co"tractor'`Namc: Lk.No. APPLICATION I PERMIT
Architect/Englnrer.
�_ BUILDING-ELECTRICALPLUMBINC MECHAMCAL CATEGORY CONTROL N
Lie.Na
``//ll QTY ELECTRIC PERMIT FEE, BUILDING PERMIT INFO
Address:? 2 h Lam. PERMITISSUANCE
LICENSED CONTRA R'S DECLARATION E] 0 D
I herebyaffirmtMtl !v Ocrosedunder eBusin androf Chapter9dA rand c APPLIANCES-RESIDENTIAL trig DESCn �
Ingwith Secifon7000)of Divlelon3olthe0usinessandl'rolessloneCade,and my - /}s(S Tit
at
license is In full fora and Affect. PANELS ,
License Class Llc.s.
Date Contractor —UP TO 2GOAHM
ARCHITECTS DECLARATION 701-I000 AMPS
00 I understand my plans shall be used As public cord. OVER 1000 AMPS ,5Q.FT. R ARG $/SQ.FT.
Licensed Professional SIGNSELECTRICAL
OWNER-BUILDER I-n DECLARATION SPECIALCIRCUIT/MISC
Z U owing rason.(SotlamexempHrom the essad Professions
License LAW city the
or
QQ ppp followingreasequimtion70313,tmco tmcialt ProfessionsemlishAny cityor
F"F'ty cvuntywhich rcqulreea permit rocessWci,alter improve,demol0h,orrepalr TEMP.MF-TER ORPOLE INST.
5 3 anystructurc private ltstssuance,also requiroathe applicant forsuch permit to
Ole a signed statement that he Isae
lland pursuant to the provisions of the LOWER DEVICES
tateme
3µ Contractor's Licenu Law(Chapter9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
07 eion3 of the Bualness and Pro(essbro Cade)orthat helsezempt there(romand VALUATION
Sn'.7 the basis for the alleged exemption. Any violation of Section 7X015 by any
G$ OUTLETSSWITCIiFSF1XTURES
Applicant I..permit subjects the applicant to a civil penalty of net more than
I reined d.1l..($500). NEWRPSIDFNTIALELECTR SQ.FT.
�n I,as owner of the property,or my employees with wages as their sole STORIES TYPE CONSTRUCTION
7 neAden,weldothe work and the structure isnot trended or offered for
sals(See 7DM,Businew and Prefesslors Code:The Contnct.e.Llcen•"Law
$ does not apply to an owner of property who builds or Improves therms,and OCC.GROUT' HES.UNITS
who does such work himself or through Ms own employees,provided that such
Improvements are not Intended muttered for sale.If,however,thebuilding er TOTAL:
improvement bsold wlthinoneyearo(completloMtheowner-bullderwlilhave
t rden of proving that he did not Wild or Improve for purpose ofsak,). QI'y, PLUMBIN R IT FEE FLOODZONE APN
L
1,as owner of the property,am exclusively mntracilng with Ilcenam PERMIT ISSUANCE
contractor"to construct the project(See.7044,Business and ProfAsAImA Code:
The Cont.d.".License Lw does not apply to an owner of property who ALTER-DRAW kVENT-WATER
bullda or improves thereon,and who contracts for such pPF'tla with a
csy�i aeor(e)Ilmased pursuant to the Contractor's License Law. FEE SUMMARY
I--i empt under Sm.,e:=', k P (or this rcawn BACK FLOW PROTECT.DEVICE
cxvDRAINS FLOOR,ROOF,AREA,CON SANITARY Y N
ser
Data RpJ.=
ORKbre COMP S 10 DECGR TIO FIX'IURFB PER TRAP SCHOOL TAX Y N
[]I ere affirm that I have a IBcet of consent to f-Insure,or a
ne to Wmkeri Comperuatl urem oracomfledeepythermf(Sec. RECEPTa
3800 ) GAS G.SYSTFAf-I INC.40UTLETS PARK FEE Y N
Coir an GAS.G.SYSTEM-OVER 4(G) RECEIPT s
Y BUILDING DIVISION FEES
Certified copy ls hod with the cit. GRGSEANDUSRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy ls filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANTEARY-MRM EA mOFi, Date Recei t#
(Ihtaactlon need not be completed If the permit ls for one hundred dollen P
($100)mless.) WATER HEATER W/VENT/EL[CTR ENERGY FEE Y N
I comlythat fn the performance of the work forwhlch this permit is issued,
I shall not employ any person in any manner so As to become subject to the WATER SYSTEM/TRGTING
Workcn'Compcnsation Gwaof Gllfornia.Date PAID
licant
Z Z OT
NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
N Code,you=at fort hwlth comply with such provisions;or this permit shall be BUILDING FEE .O
7 deemed revoked.
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE a
Il I hereby affirm that thereis a romtruction lending agency for the perform. ELECTRIC FEE
Z ance of the workforwhich thlsperrntB unded(See.30W,Civ,C.) TOTAL:
V O lenders Nam PLUMBING FEE
IL 1— LeedA?.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Iadl(ythm l have read this application and state that theabovelnformatlon
1 lsmrtect.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. relating to building construction,and hereby authorbo,representatives of this
(_ Z city to enterupon the above-mentioned property for inspection purposes, ALTIRORADDTOMECH.
_ (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
against liabilities,judgments,coats and expenses which may In anyway accrue AIR HANDLING UNIT(T010,000 CFM) SUBTOTAL•
natsaid Cityin con fibs granting o(thb p717147'21-
it. _
17 AIR HANDLING UNIT(OVER 10,000CIM) CONSTRUCTION TAX
S not reef Applicant/Col actor to EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA]AR OUSh AT MEALS DISCLOSUR
Ill the applicant or(u ire bu din occupant store or handle hazardous HEATING UMT(TO 1W,000 BTU) Date Recei t#
erlal as defined by the i soh rdpal Code,Chapter 937,and the
Health and Safety Code Sect on 75537 )7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
F1 Yes rj No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) PShIKAFUDATE
which emit havrdous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP OHP OR 100,000 BTU)
4 Yea 9 No
havernia Health
et mode, ercqulremersunder Chapter 6.95 of BOILER-COMP(OVFR 100,000 BTU)00 17 IM
the California Healthk5a(ety Code,Sectlors 255G5,25333 and 76536.1 JUL 1�/.7(�
understa red that if the building does not currently have.tenant,that it I.my NEWRESIDENTIALMECH. SQ.FT
responsibility to notify the occupant of the requirements which most be met
prior to Issuance of a Certificate of Oav pa ney. CIfY'Wf vt�r'Gh'LiP1U
Owner or authorised agent Date 1SSUEDBY:
TOTAL:
OFFICE COPY