23958 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PFRMITNO.
BuBaingwAa_�,_���2fffI Seo 23958
Phone:
wnarer IT1!/V1n�/' A
CITY OF CUPERTTN0.6UILDING DIVISION 21
Con�'sN me' Lic.No: APPLICATION /PERMIT
'" - x
Architect/Engineer. Lk.Na BUILDINGS.ECTRICALI'LIIMBINGMEC}IAMCAL CATEGORY CONTROL
`QTY ELECTRICPERMIT" FEC BUILDING PERMITINFO
Address PERMITISSUANCE ��� ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that lam BcenaM under provtlons o(CM1apter9(common APPLIANCES-RESIDENTIAL ] DESCRR'IION
Ine 00)ofon3o(theeuslneseand ProlesaonaCade,and my I�� � /�
I'licenscisinfuill....deffect. 1 PANELS �\ l?
Lkenrc Claes Lk.X /nal
Date Co enactor Up TO 200 A ^
ARCHITECTS DECLARATION 201-1000 AMP"' '
a0 O I understand my plana shag be used u public records. OVER 1000 AMPS '• R� S/SQ.FC.
ZLicensed Professional SIGNS ELECTRICAL
6 OWNEReBUILDER DECLARATION SI'Fr1ALCBtCUfT/MLSC
SII 7t'TrR'Z Iherebyaffirm lOWNER-BUILDERxempt the CantLARATor.Llanee Lawlorthe
pp N
q following reaxon.f5eon 7031.5,Business and l'rafesslov Code:An c
F7q cauntywhichrequimsapermlttomvtr Lgateglmpmvgden lBh,orrepralr TEMP.METER OR POLE INST.
�� 3 any structure prior to Its lssuaMq also requbes the pplicant for uch permit to POWER DEVICES I.
Bit,a signed rtaement that he is licensed pursuant to the provblov of the
HjO u,� Contractor,License Law(Chapter 9(mmmerang with Section 7000)of Divi- SWIMMING POOL ELECTRIC
0 sion3 ofthe Buemessaad Professlov Cadc)orthat he asexempt therefromand VALUATION
6 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS SWITCFIFSFIXT(1RES
applicant for a permit subjects the applicant to a civil penalty of not more tban
° five hundred dollars($SM.
❑I,as owner of the property,or my employees with wages as their sole I NEW RESIDENTIAL ELECTR SQFr. STORIES TYPE CONSTRUCTION
compensation,will do the work and the stroaure b not intended or offered for
C sa1e(Sec.7014,Business and Professions Code The Contractor',License law
doe,not apply to an owner of property who build,or improves thereon,and OCC.CROUP RFS.UNITS
who doesauch work himself or through his..employ.,provided that such
Improvement are not intended oroffered forsale.IL howaver,thebulldingor L;
Impmvement lssold withinoneyearafcomplOtoNtheowner-bulWerwilt have
1k11 no(proving that he did not build orlmprove for purpose ofsale.). QTY, PLUMBING PERMIT FEE plppI ZONE AIN
'cffi� owner .f the property,am exclusively mmosel ng with licensed PERMRISSUANCE
tractors to covtrua the project(Sec.7014,Business and Profenions Cade:
Contractor,License Law does not apply to an owner of property who ALTER-DRAIN&VENC-WATER(FA)
Z,
or Improves thereop
n, and who contracts for such tojecta with a
cq➢lfactor(e)Ilaneed pursuant to the Contractors Llanse Law. FEE SUMMARY
I am exempt under Sec B k P C for this reason BACK FLOW PROTECT.DEVICE
Owner Data DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
BBC=It
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of consent to mlfdFDCIIIRLS PER TRAP SCI100L TAX Y— N—
vum,or RECEIPT x
cedifimteo(Worken'Comper tion Wuranmoraartltledmpythe.f(Sec.
3800,Lab C.) GAS FA SYSCEMI WC.40IIILLTS PARK FEE Y N
Policy X RECF2pr a
Com n CAS EA.SYSTEM-OVER4 MA)
Y BUILDING DI VISION FEES
Certified copy t hercbyth theM. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy b(fled with the city ivpealon division.
CERTIFICATE OF EXEMPTION FROM WOR KER S' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SAMTARYSTORM F.A.200FT Date Remi t#
(fhb section need not be completed If the permit is;forom hundred dollen
(5100)mtyify that
Iarthe mWATER HEATER W/VENT/ELECTR ENERGYFEE Y N
t In the perforance of the work for which this permit lalswed, —
I shall not employ any person in any manner w as to become subject to the WATER SYSTEM/TREATING
O
Workers'Compensation Love of California.Date PAID
Z Applicant NEW RESIDENTIAL PLMB. SgFC. Date Recel tN
Z O NOTICE TO APPLICANT:If,dicer making this Certificate o(Exemptlon,you
should berorrc subjeet to the Workers'Compevstion provisions of the Labor TOTAL:
N Code,you most fort hwith comply with such provisions or this permit shall be
> deemed revoked. BUILDING a g CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there b a conamctlon lending agency for the perform TOTAL:
ELECTRIC FEE
LL� O anceofthework(urwhkh this permltbtssued(Sec.3097,Civ.CJ PLUM BING FEE
Lvinic.Name
LL H Lena ntiAddress qfv. MECHANICAL PERMIT FE6 MECHANICAL FEE
O W (rent.Iagre have
comply ith all ationandunty ordinances ndstatela n
M lsrorrea.Iagreeto complywith all cilyand county ordinances and state law, PERMIT ISSUANCE FEES PAID:
F'y relating to building construction,and hereby authorise repmasntativae ofthis
Z city to enter upon the above-mentioned property for Wpealon purposes. ALTERORADDTOMSCH.
V — (We)agree to save,Indemnify an a keep harmless the City of Cupertino Date ReceiptN
against ltbititles,judgments,rose a nd expenses which may in anyway same AIR HANDLING UNIT HO 10,000 CFM) SUBTOTAL;
against said City in conaaluena of the Xanling of this permit.
_ , 7 /0 9 Z AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Ig rcof A�ppl/ica�nt/fContfcto—ra D e EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WilitheapplIcant or future building occupant store or handle harardous HEATING UNIT(TO 100,000 BTU) ate Recei t9
materul as cieRnade,d by the Cupertino Municipal CoChapter9.IZ and the
Health and Safety Cade Seaton 2SS32(a)7 HEATING UNIT(OVER 100,000 BTU) TOT
❑ Yee No
WBltheapplicant or uNre building oavpant use equipment ordevlas VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havnlous air contaminants as defined by the Bay Area Air pp�k � ' D
Quality Management Dbtria2 BOILER-COMP OFR'OR 100,000 BTU) B�
4 Yea No
have read the haze us materials requlremant under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) JUL
1�
the Caltand t Health building Safety Code,Sealons mently have a 3 and,that i 1 1992
undetstandthat n he tifytheoccupant of t the
encs which that it met NEW RESIDSJ'11AL MECH. $Q.FT 4�y
responsiblllty to natty the occupant of the requirements which rtwst be met
prior to issuance of a Certificate of Occupancy. CITY UJI,'��Wrr Colli
Owner or authorized agent Date ISSUED
BY:��
' TOTAL:
OFFICE COPY