23948 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PIBRMITNO.
Building Address: a
23948
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caner. hone: A
CA7J *AD - • CITY OF CUPERTINO-BUILDING DIVISION ,
Co.°rad°:•Nave: Lm.No: APPLICATION / PERMIT
BULDING-ELECTAICA4M' BINGMECHAMCAL CATEGORY CONTROL X
Arehited/Engtnar. Lle.Na
JAwSQTY ELECTRIC PERMIT FEE ' BUILDING PERMIT INFO
Address: ,. PERMITISSUANCE ❑ 1:1 ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby aHbm that am licensed under provisions of Chapter9(comment, APPLIANCE&RESIDENPIAL JOB DESCRIPTION
Ingw iSidon force anDlvfect. fthe BuNriessand Profeasl°n.Code,and my �� -
license Is In full force and effect. PANELS
License Clam LIcX �
Date Contvdor UP TO 2DO ANTSARCHITECTS DECLARATION 201-IWO AMPS
q�❑�Evu tO Zp I understand my plare.hall be used as public records. OVER 1000 AMPS - SQ.FF.FLOOR AREA S/SQ.FT.
6� Licensed Professional SIGNS ELECTRICAL ( ti FpqS�Ty
«< OWNER-BULDER DECLARATION
SPECIAL CIRCUT/MISC
71.., owing nuesm. Sedi=7exemptfrom mess Co'mfead rot Ceee Law la the _
pp
following reason.(Sedlon 78115,liminess and Professbna Code:Any city or ) Y
O y ti TEMP.METER ORPOLE INST. _l li ,� P Y
P0 �, anystmcounty which
mpri toiftres a permit eahomquiriter,lmpmvgdenmch,er ttr
g any stmduretatemethat he
licensed pursuant
to the provision of ltte POWER DE'l'IGE$ �/ �q p_
ft,f floe a signed statement that h(Chapter Ikensed pursuant to the tion 7000) of the (® fi(G►�
Eco ContradoraLicenseLdProfefam Commenthath.lwith..pt7000)o(Dlvl- SWIMMING POOL ELECTRIC UATI
�0 t e basis fo the allege dexempl icm. Any
violation f.ection h31.5 by y
0 yd the bast for the alleged exemption. Any vtola civi of na lty o net 1.5 by any
fiveapplicentdred.permit subjedsthe appllcanitoa civil penalty of net more than OUTLETS-SWITCHES-FIXTURES
five hundred dollars($500). MRIES TYPE CONSTRUCTION
'9..' ❑I,m owner of the prep",or my employees with wages as their sole NEW RESIDENTIAL ELECTR SQ FF.
ei compensation,w0ldothe work andthe structure,b not Intended or offered for
O sale(Sec.704q Business and Professions Code:The Contado/s License Law
p R E does not apply to an owner of property who builds or Improves thereon,and OCC,CROOP RFS.UNITS
whodoea suchwork himselfmthm Igh his own employee.,provided that such
improvement are not intended or offered for sale.If,hmveveq the building or TOTAL:
improvement Isaold within oneyearoftempoeli°n,the owner-buliderwill have
11ILkurden of proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE �r
contractors to constructthe project(Sec.7654,Business and Professions Code:
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN&VENT
builds (EA)
build.or Improves thereon,and who contracts for such projects with a FEE SUMMARY
cgR[fador(s)Bareed pursuant to the Contradoes License Law, BACK FLOW pROTpGT•DEVICE•
LII am exempt under Sec. B&P C for this reason
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y N
Owner Date RECEIPTp
WORKMAN COMPENSATION DECLARATION pIXgU v PERHAP SUi00L TAX Y_ N_
Of hereby affirm that I have a certificate of Conant m copy tneurc,ore RECEIPT X
ceAfftateofWorker'Comper ewlmumana aadifled ropythereo((Sec. GAS P.A.SYSTEM-1 INC.4OUTLETS PARK FEE Y N
3000,Lab C.)
Policy X GAS EA.SYSTEM-OVER d EA) RECEIPT X
Com ny - BUILDING DIVISION FEES
dified copy b hereby furnished. GREASE/INDUSCRL WASTE INI'QtCF1'•fOA PLANCHECK FEE
Certified copy b filed with the city inspection division.
CERTIHCATEOFEXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SENrER-SANITARY-STORM EA.200Ff. Date Recei t#
(Thbsedion need not be completed lithe permit b forone hundred dollars
(5100)or less.) - WATER HEATER W/VENC/ELECTR .ENERGY FEE Y N
I artilythat in the performance of thework forwhich this permit is Issued,
I shall not employ any person in any manner so m to become who&to the WATER SYSTEM/TREATING
Workere Compensation Law.of Callfomia.Date PAID
'O Z NOTICE
Applicant NEW RESIDENTIAL PLMB, SQ.FF. Date 'Remi t#
Z O NOTICEcome mb)Mtot a after maklnm the
enCeion pro ascus,of tion,you
should become subjM to the Workers'CompewHon provtloru of the Labor TOTAL:'
V) Code,you moat forthwith comply with such provisions or this permit&hall be - W BUILDING 'E
W 7 deemed revoked. _
t1 CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby af0rrethat there is a cemtrudton lending agency for the perfom> ELEC'T'RIC FEE
Z ance ofthe work for which this permit Is Issued(Ser.3097,Civ.C.) - 1�
V O Lender's Name PLUMBING FEE sear
LL I- Lend.e.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertifythatl haveread this application and statethattheabovein(or tion
is comed.I agree to comply with all city and county ordinances and state laws - PERMITISSUANCE FEES PAID:
IL relating to building construction,and hereby authortu representatives ofthis -
)I— Z city to enter upon the abovcmentioned property for inspection purposes. ALTER OR ADD TO MECH. ROCeIJ)t#
Z (We)agree to save,indemnify an d keep harmless the City of Cupertino Date
against liabi101es,judgments,maimed expenses which may In anywayactrue AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL'
a airet said Ci In consequence of the grantingotthle reit CONSTRUCTION TAX
AIR HANDLING UNIT(OVER 10,000CPM7
IgnaNre o(A Ilam/Co dor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
FIA2AR0DUB MATERIALS DISCLOSURE
Will the appheant orfudlm building occupant stare or handle hazardous HEATING UNIT CIO 100,000 BTU) Date Recei [#
material as defined by the Cupertino Municipal Code,Chapter 9AZ and the
Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTA �•
❑Ye. r]No
Will the applicant orfulure building occupant use equipment or devices VENTILATION PAN(SINGLE MID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP 0HP OR 100,000 BTU)
Yes N No
ze o
have read the Faus materials requirement under Chapter 6.95 of BOILER-C•OMP(OVER 100,000 BTU) �jpy
the Calflornia Health&Safety Code,Sections 25505,25533 and 25534.] j+ 4
understa nd that If the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FF. s"
responsibility to notify the occupant of the requirements which at be and
prior�tlVo�issuance of a Certificate of Occupancy. • V `�
Owm1.r authorlud agent . Date -
ClI Y
TOTAL: IISSUEDB
VU
OFFICE COPY