23012 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PE(MITNO.
Building Addrc,,:
23012
Zo_y8o SYEv S E I�1 �P•
ners one: APPLICAM
F00_rA#jAS T T CITY OF CUPERTINO�BUILDING DIVISION
Contractor's Name: r-ICT Lie.No: APPLICATION /PERMIT I l
0,0 " ` 17y 3 BUILDING-19.ECTRICALDLUMBINC-MECIiAMCAL CATEGORY CONTROL N'
ArcMtet/ gtneer. Lk.No:
'QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address:' PERMITISSUANCE �� ❑ � ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
IMrcby affirm that l am Bcensed under provisions of Chapter9(commene APPLIANCFSRESIDE•fIIAL JOB DFSCRBr1TON
le,cmeh infull forceofd effeon3o(the Buslnevand ProfnsionsCode,andm
LIc.m Is in full force and effect PANELS
License Clay ,71 4103 7
Date_u•7 CHITEtorSDEC �s IN[,,
ARChall be used
as public
OVER 10AMI'S
p�p�uup7 Iundemtand my pkmehaBbe uxd apublic records OVER]OrO AMPS SQ.FT.FLOOR ARTA S/SQ.FT.
6i Licensed Professional SIGNS ELECTRICAL W A L E D IN
<< OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC LA
7f, � lowing rason.(hatlamexemptfromthed Profession.
rofessio.Ccd.:law city oe OpA .�ra{a
Q
following mclumatlonfofttoconsinem and Pimprov,Cnde:Any city or v 'V'
O Z'• TEMP.METER OR POLE[NST.
cauntywhkh rctrylmapertNt to romtiut,alter,improve,demolbh,orrcpalr
9
anystmture ptlorto its basance,abo requires the applicant for such pemet to POWER DEVICES {//ATE / �{
(� file a signed deterrent that he Is licensed pursuant to the provhlom of the {M �O 1
3 w Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC f
SOS slon3ofthe Businessand Profemlom Code)orthathehexempithcmfromand VALUATION
Sr'
,;Pr for the alleged exemption. Any violation of Se tion 7031.5 by ao
applicant krapemdt eubjechtheapplicanttoativll pemlty afnt morcthan UTLE9'SSWTTCHESFIXfURPS
$ qP
five hundred dollars($500). NEW RESIDENTIAL EL1iCTR
n I,as owner of the property,or my employees with wages as their sole SQ.FL STORIES TYPE CONSTRUCTION
J_ compensation,will do the work and the structure to not intended or offered for C t
$ O sale(Sec.70Cy Business and Pro(eeslam Code:TW Contractors Llceme Law
does not apply to an owner of property who builds or improves thereon.and OCC.CROUP RIS.UNITS
who doessuch work himself orthrough hlsown employees,provided that such
Improvements are notIntended oroffered forsak.1L however,thebullding or TO
Improvementhsoldwllhln oneyearofeemplelbn,the owner-budderwlll have
t burden of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PER FEE" 1q,OODPDNE APN
I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCEcontntms to construct the project(Sec 7096,Businessand Professions Code:
The Contmtori License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(PA)
Wilds or improves thereon,and who contracts for such pnojecta with a
cgp[(ator(s)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE - FEE SUMMARY
LII am exempt under Sec B &P C for that reason
Owner Data DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
RECEIPT N
WORT that COMPENSATION DECLARATION FIXTURES-PER TRAP SCITOOL TAX Y N
❑1 hereby affirm that T have o Imur to of concent m copy
ora RECEIPT M
certificate ofWorken'Compematlonlmurance ora certified copy themo((Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3500,Leat C3
Policy p RECGAS FA.SYSTEM-OVER 4(FA) DING DI M
Com any BUILDING DIVISION FEES
Certified copy h hereby❑ th the city hh
Certi/led copy h(lied with the
inspection division. GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA XpFI. Date Recei t#
RNs section need est be complied[(the permitat(Drone hundred dollars
($100)orlessJ
I certify that In the performance of the work for which thisb hWATER HEATER W/VENT/ELECTR ENERGY FEE Y permit
Issued, —
N
I shall not employ any pereon In any manner so u to become sublet to the WATER SYSTEM/TREATING
Worompensatlon laws of California Date PAID
Z Applicantlicant NEWRESIDPNIIALPLMB. �FI. Date Recei t#
Z NOTICE TO APPLICANT:[(,after nuking l his Certlk to of Exemption,you
Hshould become subject to the Workers'Compensation provisions of the Labor - TOTAL:
i.n Code,you=at forthwith comply with such provision,orchis permit shall be
deemed revoked. B
W O CONSTRUCTION LENDING AGENCY SEISMIC FEE
11ILDING FEE
a -Ihercbyafflrmthat therehemmwctlon kndingagenry forth per(omt ELECTRIC FEE
Z ance of the work for which this permit h Issued(Sec.3097,Civ.C.) TOTAL:
00 Lenders Nana PLUMBING FEE
LL )— Lenders Addre„ QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icenlfythatl have read thhapplimtlonand statethattheabove Information
6 ico et.Iagree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEE$PAID:
>. Nrelating to Wilding construction,and hereby authortre representatives of that
Z city to enter upon the above-mentioned property,for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,Indemhfy an d keep harmless the City of Cu pertho Date Reeei t#
V against liabilities,Pdgments,costs a cad expenses which in any way accrue AIR HANDLING UNIT CFO 10,000 CPM) SUBTOTAL:
against said Ity in cons sof the granting of this pertnlL AIR HANDLING UNIT(OVER]0,000CEM) CONSTRUCTION TAX
mm ll. •a-t
Sign ture p i nt%CTont ctor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
AZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UMT(T0100,000 BTU)
mDate RecCT [#
aterial as defined by the Cupertino Municipal Code,Chapter 9.1Z and the
Pkallh and Safety Codr ton 25537h)7 HEATING UNIT(OVER IDg000 BTU, TOTAL
F-1 Yes o
Wllltheapplicanto future building occupant use equipment ordevices VENTILATION FAN(SINGLE RISID) ISSUANCE DATE
whlchemlthavrdous rcontaminant,as defined by the Bay Arca Air 2� ����
Quality Mamgement Dattrlct7 BOILER-COMP(3HPOR 100,000 BTU) NOVYaa gyp V
4have UHd .th& fZ tm dl ,SarequlremenbunderChaphr6.95 of BO LER-COMP(OV R)00,000BN)
the Califomk Health&Safety Code,Setlom 25505,25533 and 25539. 1 /•Ur G,Ij 1[IVU
reapmtsndthat ifthethe building does note currently have a tenant that It h my NEW RESIDENTIAL MBCii. SQ.[T. C1YY UfV
respomibllitymntity the occupant of the requirements which must he met _
prim,jpQjssua ofaCe llrate of Occupanry.
1G7 / 1-20 -7/ UEDB
Qv er orawho' a DateeUEDO ISS
TOTAL:
OFFICE COPY