21578 APPLICANT TO'FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
Bufidl.g Pro'ed Identification - - PERMIT NO.
Building Address:
1.:f� ,
p� 4 s E ��i7r,� o�sd- ib .21 .578,
` rC:t7B C � S'qnxy 42,4kr5-67 CITY OF CUPERTINO-BUILDING DIVISION A
Contraaor'aName: LIC,No, APPLICATION I PERMIT '7- 17-
BUILDING
_ELECTRICALpLUMBINC MECHANICAL CATEGORY CONTROL p
Architect/Engineer. Lk.N
Q?Y ELEGTRI'C PP,R�[vITT ",`:FEE "`,B/UILDINGPERMIT,INFO: •',
Address: PERMITISSUANCE IyC '❑ ❑ '❑ .
LICENSED CONTRACTOR'S DECLARATIONLJ
Thereby affbmthatlam licensed underprovbion.o(Chapter9(comment- APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwith Sedlon7OOO)of Division3ofthe Buslnessand PmfeWonsCode,and my ,
license taint. o deflect PANELS
Llcen Ice Cmar �R G /� �,•"'_ R K /�,
Dale G ser *}0/j
ARCHITECTS - 0 AMPS
Q�av ❑O [understand my plans shall be used ypublic reroOVER1
records. OVER 1000 AMT'S SQ.FT.FLOOR AREA S/SQ.FT.
61z Licensed Professional SIGNS ELECTRICAL _
Q. OWNER-BUILDER DECLARATION
!n �3 SPECIAL CIRCUIT/MISC
L, owing rason.(h on701.5,BuI am exempt romthe Contractors License LawAny cit or
he
02 ap county followingreason.irecdon7nsttocuslnese and Professions Code:Any city it TEETP.METER OR POLE INST.
P W county which requireaa permitrorowtruct,alter,improve,demolish,or repair - ,
a any structure prior to its Issuance,also requires the applicant for such permit to
file a signed statement that he Is licensed pursuant to the provisions of the POWER DEVICES
Owt. Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
30`8 sion 3 ofthaBuslness and Processions Code)orthat he is,exempttherefromand VALUATIIO,JNs
6 5, the basis for the alleged exemption. Any violation of Stolon 7031.5 by any OUTLETSSWITCHES-FIXTURES
app@ant for a permit subjects the applicant to a elvll penalty of not mare than
five hundred dollars($500).
I,as owner of the roe NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
property,k a or my employees with wages r their sole
compensation,Business work andthesavoursis cart intended oressanalfor
q sale(Sec;pply 70K to alnesaandf property Cods;The Contractors Llceron Law
r3 does not apply to an owner of property who Wilda or Improves thereon,and OCC.GROUP RFS.UNITS
EE
who doessuch mentsa norintelf or ndedorough his own ale.If owevrovldedthatsuch
improvemndissonotithindneyearferect for pldio.](,ho es, buflderwdI have TOTAL: ,
improvementbeold within oneyearo(completloMtheowner-budderwlll have
thrdenofpmvingthathedid notbuBdorimprove(orpurposeofsale.).• O'Ily;'.;� ,. ]r�umilNCiPMIT t
ER
� t " 4FEE:;, FLOOD ZONE APN
I,as owner of the property,am exduelvely contracting with licensed
contractors to construct the project(Sec.70K Business and Professions Code: PERMIT ISSUANCE
The Contractor.License Law dues not apply to an ownerM property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves,thereon, and who contracts for such projects with a '''4FEB SUMMARY;,'
TlactLl
or(s)licensed pursuant to the Contractor.License Law. BACK FLOW pROTFGT.DEVICE "' x
I
am exempt under Sec. B A P C for this reasonOUTSIDE FIES
- # DRAINS FLOOR A,ROOF,ARECONE). SANITARY Y N
• Owner Data RECER'1'p
WORK MAN COMPENSATION DECLARATION SCHOOL TAX Y N
hereby�afflrm that I have a certificate of consent to eeB-Inwre,ora PER TRAP RECEIPT a
certificate of Worksm'Compomationlasurance or a certified copythereof(Sec.
3800,Lab Q) AS Vex UE 7T TW PARK FEE Y N
Paige G13 /07P03 - I RECEIPT«
Co-m env n iZ/7 /P! GAS -(J� d BUILDING DIVISION FEES
jCertined copy la hereby famished. I
REASE/INDUSTRL WAS TOR PLANCIIECK FEE
Fy kfal(ied copy b filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' REASE PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200177. - Date Rett'[ [#
(TNssection need not be completed if the permit Is fwone hundred dollars
($100)orless.I WATER HEATER w/VENT/ELECTR ENERGY FEE Y_ N
I rertifythat In the performance of thewwk forwMch tMs permit Is Issued,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workera'Compensatlonfaws of California.Date - PAID
-
Z Z Applicant - NEW RESIDENTIAL['LMB. SO.Ff. Date Recei [#
Z O NOTICETOAPPLICANT:If,after makingthis Certlfioateof Exemption,you
should become subject to the Workers'Comperuatlon provbiow of the Labor TOTAL:
to
Code,you=at forthwith comply with such provisions orthis peratahall be
W j deemed revoked. WILDING FEE a
IL — CONSTRUCTION LENDING AGENCY SEISMIC FEE
IL IherebyafErm that there be mrutruRlon lending agency for the perform ELECTRIC FEE
Z ance of the work for which this permit is Issued(See.3097,Civ,Q TOTAL
02 Lender.Name PLUMBING FEE
LL H LeodersAddress Q1',Y• 'MECHANICAGtR,ERMIT x .t t:'% FEE
WIceutilythat I havereadthbapplicatlonand statethatthe above information MECHANICAL FEE
1 Iscomact.I a gree to comply with all city and county ordinances and state laws PERMTTISSUANCE FEES PAID:
} y, relating to building construction,and hereby authomae representatives ofthis
(_ Z citR,,�a
pon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. Date Reeei f#
ar save„Indemnify and keep harmiessthe City ofCpertinoPagilltkajudgments,ros[sand exp awhkh may In anywayacerue AIR HANDLING UMT(T010,000 CFM) SUBTOTAL•
Ci in cons uenceo egrIng of this permit
-7 AIR HANDLING UNIT(OVER 10,000CEM) CONSTRUCTION TAX
Signature of pplicant/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or hand le havardous HEATING UNIT(TO 100,000 BTU) Date .. - Recei I# '
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Healthand Safety Code Se 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes
Will the applicant Mrs contaminants
ompandby the Bay Area devices VEMIWTIONPAN(SINGLE RESID) ISSUANCE DATE
which emit ha ammo Distrontaminantecect defined by the Bay Area Air
• lily Management District? BOILER-COMP(3M'OR 100,f1(q BTU) AID
4Yes ,LI,.,(�v/ HS
haveread then aety Code,Se requi25505,aunder Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the Celifarnie Health Aildin Code, currently
have
a tend,that I
' u rad that ifthe building dace not arrently have.tenant,that itbmy NEW RESIDENTIAL MECH. SQ.FT. I=} C
ria iliry to notify the occupant of the rcqui mems which must be met
p i to ssuanc a y the c panry o '/Illy w/Tye
� `uj Wi l6l
r or authorized agent ' Date - ISSUEDH
TOTAL:
OFFICE COPY *'