23777 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect identification IPERMIT NO.
Building Address: 2^7 r7 7
DO O G3 /
wnr. rime: one: A A A
M R m RA Col r& L CITY OF CUPERTINO-BUILDINGDIVISION
Ccoma`ct.e.NNaame:: �� Lie.No: APPLICATION I PERMIT
�W^� `awes. BUILDINGELECTRICAI PLUMBING-MECHANICAL CATEGORY CONTROL#
Architect/engineer.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: YL PERMITISSUANCE {�
LICENSED CONTRACTOR'S DECLARATION Lf
I hereby affirm that l am licensed under provisions of Chapter 9(commenc- APPUANCFSRESIDENUAL JOB DESCRI'IION
Ing witht...1 .fullection 7000)ofdaffect. Bust nd Pm(essionaCode,andm 1
Lunr<Ic ins lorce and efface. `/03 PANFIS .s,
Date= Lit
Con.norUP TO 200AMPS ` ` �I `•—V
ARCHITECT'S DECLARATION 201-1000 AMPS
q�v 9 Z I understand my plans ahal be used as pubbe records. OVER 1000 AMPS SQ.Fr.FLOOR AREA 5/SQ.FT.
Z�I=) Licensed Professional SIGNS ELECTRICAL
Q OWNEReBUILDER DECLARATION SPECIAL CIRCUIT/MISC Ll-r-r--y T E ����III
[hereby a(firmthatlam exemptlromthe Contractor's Llcenx Lw(or the 9r'
XO_— following reason.(Seaton 7031.5,Business and Profensiona Code:Any city or
K,Z Fpp'� county which requlresa permit tomnstma,atter,Improve,demoLLsh,orrepair T�PMETERORPOLEINST.
�e`� a any.eedure prior to its ismance,alsorequirestheapplicant forsuch permitto POWER DEVICES
0.O file a signed statement that heat licensed pursuant to the provisions of the
d3w� Contractor's License Law(Chapter 9(romnendngwith Section 70m)ofDiet SWIMMING POOL ELECTRIC
t„�OS sion3oftha Buaa
tnsand Profamir ionsCods)orthat heexempt therefromand VALUATION
the britt for the alleged exemptbn. Any violation of Section 70115 by any
Iry�6$ aPPBant(ora permitsubjectseheapplkanteoa dull penaltydna morethan U7LETSBWITCHESFlXTURES
66 five hundred delta.(SSM. NEW RESIDENTIAL ELECTR
❑1,as owner of the property,or my employees with wages as their sok SQ. STORIES TYPE CONSTRICTION
compensation,will dothe worK and thestructure at not intended or offered for
$ O sale(Sec 704q Business and Pretensions Code:The Contractors License Taw
S docs not apply to an owner of property who builds or Improves thereon,and OCC.GROUP Rhin.UNITS
who docs such work himselforthrough Ms own employees,provided that rich
impowemenm arenotintended orolfered forxla.I(,however,thebulldinger
improvement atsold within oneyearofcompletion,the owner-bullderwill have
t relanef pmArgthat he did not wild orimprove for wrposeof.le.). QTY. PLUMBING PERMIT FEE FLooDzONE APN
It
L as owner of the property,am exclusively contraaing with licensed pp RI55UANCE _
contractors
eo comtruct the project(Sec.70K Business and Professions Code:
11e Contractor's License Taw dm not apply to an owner d Property who ALTER-DRAIN&VFM-WATER(EA)
Wilds or Improve.thereon,and who contract. for ouch p�ojem with a
rgII[faaar(s)Bunsed pursuant to the Contractor'.License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B k P C for that reason
OUTSI DE FEES
Owner Data DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N
WORKMAN COMPENSATION DECIARATION RECEIn N
ereby affirm that I have a urtifiette of consent to self-inure,or a MTURE-PER TRAP �� SCIi00L TAX Y N
nificetecfWork Compem tionimur moracenifiedcopythen»((Sec. RECEIPT
SOO,Iab C.) GAS EA.SYSTEM-I INC4 OUTLETS PARK FEE Y_ N
P.)HyM _ RECEIPT#
Cam any GAS EA.SYSTEM-OVER4(EA) BUILDING DIVISION FEES
MCertBied Cumffed copy at hembytehed. GREASE/INDUSIRL WASTE INTERCEIFOR PLANCHECK FEE
� ropy at([led withh the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(fhianaelonneed natbecomplated lithe permit Elf o..re hundred dollars SEWER-SANITARY-STORM EA.200FT. Date Remi t#
(5100)orlensJ WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I certify that N can pamon ace of the workmanner
so as to i this penult cIssued, —
1 shall not employ any person In any manner ao a to Wrome.object to the
Workeri Compensation Lawn of Gli(ornla. Date WATER SYSTEM/TREATING PAID
O Z Applicant
Z O NOTICETO APPLICANT.If,after nuking thisCertificate of Exemptlogyou NEW RESIDENTIAL PLMB. SQFr. DatO Remi t#
Hshou Id become subject to the Warkeri Compmuation provatton of the Labor
WN Code,you moat fon hieth comply with such provisiopermitor this permit shall be TOTAL:
> deemed revoked. BUILDING -E
CL p CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby a!(Irm that there at a comwctlon lending agency(or the perform
Z anu ofthe work for which thin permit la lssued(See 3097,Civ.C.) ELECTRIC FEE
T I
V O Larder'.Name PLUMBING FEE �.
LL F Lenders Address; QTY. MECHANICAL PERMIT FEE
O W Iceni(ythat I have readthatapplicatlornd etatethauMECHANICAL FEE
heabove information ^.
IL isrorrect.I agreeto comply with all city and county ordinances and state laws L PERMIT ISSUANCE FEES PAID:
} W relating to building contmctlon,and hereby author@e representatives ofthis
F Z dtytoenteru .the aWvnmxoksn property for Inspection purposes. ALTERORADDTOMFCH.
— (We)a ee to ve,in centrally an it keep harmless the City f Cu penin Date Receipt#
agaWtI all[lit[' ,' dg v, sa expenseswhich yi ywayacuue AIR HANDLING UNIT ITO 10,0ee CFM)
against Cu nen egranting e L SUBTOTAL:
AIR HANDLING UNIT(OVER 10,"CFM) CONSTRUCTION TAX
Igmu moi ApPH. I once r Date EKHAUSTHOOD(W/DICT) CONSTRUCTION TAX PAID:
HA ZAR)OUSMATERIALS SCLOSURE
Wllltheappllont or fu turebulldingouvpa t store or handle hazardous HEAUNGUMT(TO100,WOBTU)
mnterizlasdefinedby the Cupertino Municipal Code,Chapter 9.12,and the Date Recei t#
Hr.Ith and SafetyCode Section 2S532(a)?
❑ Yes No HEATING UNIT(OVER 100,000 6TT) TOTAL:
Witltheappitcantorfnum bee ilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
•
Quality Management District? BOILER-GOMP(3HPOR 100,000 BTU)
n Yes g No ((��s A
haveread Healthe h
ar et Cudr,Soctiomials 2555,2553 aChapter.1 of BOILER-COMP 700,000 BTU) L" pY pT
the California Heath &Safety Code,Section 25505,mntly ve a t and 25534.1 LJ'
usponsi ndy at lithe the occupant
not a requirmnts tenant that it boy NEW RESIDFNHAL MECH. SQ.7 JUN
responsibility to Issuance
of a Certificate
of clupemqulrementawhich muatWmet �� 199
prior to Issuance of a Certificate of Occupancy. ##,
Owner or authonud agent page
Curs <
/— ISSUED BY:
OFFICE COPY
i