20749 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT'PEN ONLY
Building Project Identification - PERMIT NO.`.
Buuding Address: - '
3 �94enu 1) 1,. 20749
wne�s ams. phone: q "
VIt CITY OF CUP ERTINO-BUILDING DIVISION
c actoraN me Lie.No- ..APPLICATION /PERMIT
I(� C.D' SOSS2 BUILDING-ELECTRICALnL BINC-MECFIAMCAL CATEGORY CONTROL•#
Architect/Engineen 'Lic.No:
1 ,se 'tECTRIG"IE.AMTTx,t :ttI FEE,4 tt ItLGDINGpERMIT'INFO OTY *L11114 I'll Address. aQ
,
T PERMITISSUANCE ❑ ❑ ❑
' LICENSED CONTRACTOR'S DECLARATION
Ihereby affirmth 11 am licensed under provisions of Chapter 9(commsnc APPLIANCESRESIDENTIAL JOB DESCRR'TION
IngwlthgeR1on7000)o(Division3 ofthe Budneasand Professions Code,and my
license is in fu fo daffect. PANELS - -
Lkans�ClassLl,# SO �.
Date/ f3- Contractor IP(VNb1 UP TO 200AMPS
111� �U �,Lpl
ARCHITECTS DECLARATION i 701-1000 AMPS -
Oz I understandmy plane shelf be used w public records. OVERIOOOAMPS SQ.FT.FLOOR AREA $/SQ.Ff..
q O
Licensed Professional - SIGNSELECTRICAL
<� a OWNSR-BUILDER DECLARATION SPECIALCEiCU[T/MISC
z para thereby affimthat I am exempt from the Contractor'sLicense Law forthe
o following reason (Section 7I91S,Business and Profeaslo s Code:Any dty or
county which requires'apermit m conanue"ter,improve demolish,or repair TEMP.METER OR POLE INST.
any stmdurepdort.itsissuance;alsorequimstheapplimnifwsuchpermitto
t5 a0 file a signed statement that he is licensed pursuant to the provisions of the •POWER DEVICES
ElOnContractors License Law(Chapter 9(commenting with Section 7000)of Divi.
slon3o(th.Huatnessand Profemlom Code)orthathehexempttherefmmandSWIMMING POOL ELECTRIC VALUATION ,
the basis for the alleged exemption.,Any violation of Section 71131.5 by any OUTLETSSWITCHESFIXTURES
spplf.nt for a permt subjedathe applicant to a dvll penalty d not morethan
O
five hundred delta.($500).
F-11,as owner of the property;or on,employees with wages as their sole, NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
compena ider,will do the work and the structure is not intended or offend for
q sale(Sec.7054 Business and Professions Code:The Contractors License Law '
3� does not apply to an owner of property who W lids or improves thereon,and - OCC.GROUP - RES.UMTS
who doessuch work himself orthreugh his own employees,provided that such
Improvements are not Intended or offered for sale.If,however,the Wilding or NOTAL:
improvement is sold within one year oicomplefon,the owner-bulldeiwillh e - L -
the Iden of proving that he did not Wild or improve for purpose of sale), QTY,Ty ytt pEU1vIBINGjpERMhTt t{� t'?]'FEES"• FLOOD ZONE APN
�cton owner of the property,am exclusively...trading with licensed PERMIT ISSUANCE
rontracfors to construct the project(Sec.7044,Business and Professbns Code: -
Tbe Contrador's License Law does not apply to an owner.of property who ATER- •N , [Jd `
bulldwor Improves thereon, and who contracts(or such.ptojecwith a , , ,DRAIN&VENT'-WATER(EA)
h L
S
g0l�ador(s)licensed pursuant to the Contractors License Law.
ec ?);tT.:x)tts ,} ?FBS SUMivIARYtt
c Lf I am'exempt under SB&P C for this reason _ BACK FLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,COND. SANITARY, Y N
Owner Date . - RECEIPT It
t WORKMAN COMPENSATION DECLARATION FIXTURES PFR TRAP vie SCHOOLTAX ,Y N_
1( ❑I hereby affirm that I have a leasurate of consent m opytneure,Dr r. V RECEIPT If '
certificate o(WDrkere'Comperuatlonlrourance oracertifled copy thereD((Sec. .,GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE � Y N'
3800,
I'olky CAS EA:SYSTCM-OVER4(EA) I , I RECEIPT It `
nY' - BUILDING DIVISION FEES
Certified.pyct hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCFIECK FEE- -
❑Certified ropybflled withthe dty Wpectiondi lion. - -
' CERTIFICATE OFUEMPTION FROM WORKERS' GREASE TRAP_.' PAID
COMPENSATION IAt CE
DseDate' Redei! (#hisctlon need not be completed lithe eper perMtis!Drone hundred dolian SEWER-SANITARY-STORMEA.WOF. - '
'($100)Iamity that
_ .• WATERHEATERIN/VENT/ELECTR ENERGY FEE Y N
I certlfythat N thny per on In a n tho rworkner forwhlch this permit le issued, —
1=11 I shall not ny person in any manner so ae tuye.}oq eWriert so the WA"CFA SYSTEM/TREATING ' s
not
Laws BE la'.Date / /�'�TV PAID
O Z Appllwnt //✓ NEW RESIDENTIAL PLMB. SQ.FI'. Date V Rece) t#
Z p NOTTC�PLICAN'I': (,a r making this Certificate of Exemption,you'"r should ecame,sub)ed to the Workers'Compensation provisions ofthe Labor TOTAL,-
-
W Code,you=atforthwithcomply with such provisions orthls partiadshallbe
deemed revoked. '- _ B 'FE
W
_CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirmthat there Is a construction lendingagenry,for the perform- ELECTRIC FEE
Z ance afthe work for which this permit Ca Issued 3097,Civ. TOTAL gain
U'O Lenders Name PLUMBING FEE
LL I- Lender.Adderss - - QTY.a` �1'fEGHANIOAL,PERMIT* ,'',FEE$}< MECHANICAL FEE Q D
O W Icertifythatlhave read this appllcationand ctatethattheaboveinformation
a urormet.I agreeto comply with all city and county ordinances and Aate laws PERMITIESUANCE FEES PAID:
�. reN
relating tobulldingenoutruon,end ladebyauth.mee se
reprentativesofthin
(— Z.,• cityto enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH. '
(We)agme tD save;indemnify an d keep harmless the City of Cupertino' - Date Receipt#
ga net abilitic.,ry men costs and expenses which may in anywayamme MIEHANDLINGUNfI(TO10,000CiM). SUBTOTAL:
aid 1 Dns the granting of this ermlt.
,.✓�� ?_,qO AIR HANDLING EMT(OVER I0,000CFM) CONSTRUCTION TAX
-
Ignatu sof ApplicanOContractor / Data EXHAUST HOOD'(W/DUCT) " CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE ^Will the applicant or future building occupant store or handle hazardous. HEATING UMT(TO 100,000 BTU) -
material asdefined bytheCugggggg��eeeerllnoMunlcipalCod,Chapter 9.17,and the Date Remi t#
Health and Safety Code 75532G)7 HEATING UNIT 100,000 BTU) TOTAL:
REnJ Yes No
111he applicant or future building occupant use equip for devices VENTILATION FAN(SINGLE RFSID) •I$$l I1IC.F#.QATE
' which enut hazardous air cont ..ants as defined by the Bay Area Air, - - �R,pNy��
Quality Management Dutra BOILER-COMP DEEP OR 100,0(10 BTU)
4 Yes o
haveread the bazar ous materials requirements under Chapter 6.95 of ' BOILER-COMP(OVER 100,000 BTU)
the California Health&Safety Code,Sections 75505,75533 and 75534.'I' V U l
` understand that ifthe building docs not currently have a tenant,that it is�my NEW RESIDENTIAL MECH. SQ.FT sponsibility to notify the occupant of the requiremente which must be rnat dty Qf,COMM(*1'fl
priortouanceofa Cedifkateof Occupancy. -
Owner or authorizodagent - 3 Ous _ - 15SUGD BY:S`
TOTAL:
OFFICE COPY