23964 APPLICANT TO FILL,IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY,
Building Project Identification PE1 TNO.
nBdin Address: Wow/ C* 95o w.- � - 23964
�e c�rr�
hone:• A
-. n61u -LV tjs �e CITY OF CUPERTINO-BUILDING DIVISION
Contrarsora Name: Lle,No APPLICATION / PERMIT
BUILDINGELECTRICAUPLUMBINGMECHAMCAL CATEGORY CONTROL N
Architect/Engineer. Lk.Na
- QTY', t l� PtELEGTRICI$EkR1y11T 1'ttl` " "EEC,-j �'t'Sa BUILDING PERMIT INFO•- j, ??"C ' .
Addresm PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION '
I hereby afttrmthat l am licensedunderprovislon..f Chaptcr9(mmmenc- APPLIANCES-RESIDENTIAL J Nr,.
ingwithSOlon7OM)of Divislon3otthe BusinessandProfemionsCode,and my'
license is to full force and effect PANELS J •T
License Class - Lic.N _ a•a'r�,'
Date Contractor % �` rY
- ARCHITECTS DECLARATION 201-1000 AMTS
ce
wZ I understand my plashall be used as public records: OVER 1000 AMPS SQ.FT.FLOOR AREA. $/SQ.FT.
plans shall
Licensed Professional _
SICNS ELECTRICAL
6 - OWNER-BUILDER DECLARATION - PECIAL CIRCUIT/MIST '
i.., Ihereby affirm that l am exempt from the Contractor's License Law for the -
7.O 3 following reason.(Section 7EGLS,Business and Professions Code:Any city or -
O'y t. TEMP.METER OR]'OLE]NST. '
�� rountycture requires.pxuanx,cororequir theaprovgdeiuollsh,ormlitr
any structure priorto statement
Issuance,alursuaapp the.prrsuchpeofNt a ppyygR DEVICES
2 a filed signed statement[hat he is 9(colicensed pursuant it LSe tion 70oru f the
�ja��j�j'�'�'� Contractor's License law(Chapterg(commencing with Section 70[c)of VALUA
EOS sion3ofthe Businessand Profewss mCode)urthagheieexempttherefmmand SWIMMING POOL ELECTRIC -• ") �S
the basis for the alleged exemption. Any violation of Section 70313 byany uTEEPs-SWITCHES-FIXTURTES
Og
applicant for a permit subjects the applicant to a civil penalty ofnet morethan
tiv uedred dollars(S500).
as owner of the property,or my employees with wages as their sole NEW RESIDENTIAL ELECTR SQFI'. STORIES TYPE CONSTRUCTION
�Za npensation,will do the work,and the structure is not Intended or offered for t '
0 sale(Sec.7044,Business and Profeaslons Code:The Contractor's License Law
r$ does not apply to an owner of property who builds or improves thereon,and
3^ who does such work himself orthrough his own employees,provided that such - OCC.GROUP RFS.UMTS
improvements are not intended oroffered forsals.If,however,thebutlding orOr
Improvementiasoldwithinoneyearofcompletiogthemvner-bbdderwlllt ve - -
te rden of proving that he did not build or Improve for purpose oleate.). 'QTY, :',• �.'iPLIJMBIN"GPERMIT,1zt "%'; 4OFEE'1F FLOOD ZONE APN
11,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE„
• contractors to construct the project(Sec.70K Business and Protrasiow Code: q -- .
The Conteictor's License Law does not apply to an owner of property who Ay.yEg DRAIN k VENTWATER(EA)
Wilds or Improves'thereon, and who contracts for such pwoets with a
ruj LI[actors)Bcensed pursuant W the Contractors License Law. 4,t"„°1='. ,;¢,'•;,I;FEE'SlIl1'TMARY ( . ,'i
. BACKFLOW PROTECT.DEVICE
LII am exempt under Seca B k P C for this reison OUTSIDE FEES
DRAINS FLOOR,ROOF,AREA,CO ND. SANITARY Y_ N_
Owner Date' RECEIPT p
WORK MAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOL TAX Y�_ N_
01 hereby affirm that I have on Trttficate of consent m copy
theure,ora RECEIPT N
certificate of Workers'Comper�satlon lnsuranceora certified copy thereof(Sec. GAS EA.SIMTEM-1 INCAOUTLETS PARKFEE Y- - N
polis38m,Lab C3 RECEIPT N
'I'o11ry N GAS-EA.SYSTEM-OVER 4(FA)
Com any BUILDING DIVISION FEES
[�CertlEed copy is herebyI'
the city GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certi(ieA copy la(]led with the city Inspersion division.
CERTIFICATE OF EXEMPTION FROM WORKER S' GREASETRAP PAID
COMPENSATION INSURANCE -
-(This section need not be completed lithe permit ls forone hundred dollars SEWER-SANITARY-STORM FA,200FT. Date Recei t#
($100ce.rfres riess.) '
I hat in the peHmareWATERHEATERW/VENT/ELECTR ENERGY FEE Y N
ona(the work for which this permit la issued, .T
I shall not employ any peri In any manner an as to become subject to the WATER SYSTP.N./TREATING ,
workers'Compensation laws of California.Date PAID
licant
_Z ZNOTICE TO APPLICANT:If,after making this Certificate of Exemption,you Now READENTfAL PLMB. SQPT. Dale Recei t#
should become subject to the WorkersCompensation provisions ofthe Labor - TOTAL'-
I'm N Cade,you must forthwith comply with such provisions orthis permit shall be �+
CC d3med revoked. - - BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL I hereby attirm that there is a construction lending agency for the perform- ELECTRIC FEE
Z once of the work for which this permit lassue
id(Sec.3097,Cl,C.)
V O Lender's Name - - ., PLUMBING FE
H ] E aaxr
IL 4nder'.Addrea. QTY. ,[ `•'MECHANICAL PERM IT FEE'tl MECHANICAL FEE
U Imrtify that have mad this application and state that the above Information
O W Iscorrect.I agree to complywith all cityand county ordinanm and gate laws PERMIT ISSUANCE FEES PAID:
} 0 relating Ing construction,and hereby authorize representatives ofthis
N city to terupo the above- timed property for inspection purposes. ALTER OR ADD TO METH.
Z (Wel a save,Inde I(y and keep Me as the Clty of Cupertino Date Receipt#
V against 11 re e ju lints ssfcandex e s vhkh mayt o vayanere. AIR HANDLING UNIT CFO 10,000CFM) SUBTOTAL:
against.. s a of this er it.,
' Z AIR HANDLING UNIT(OVER 10,000 CIM) CONSTRUCTIONS TAX
Signature of Applicant/Cottm re t EXHAUST HOOD(W/DUCT) CONSTRUCTION,TAX PAID:
HAZA R DOUS MATERIALS DISCL SURE
Will the applicant or future building occupant store or handle haaardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
i material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health
Yes and Safety CodeSSelioon25532(a)? HEATING UNIT(OVER 100,000 BTU) - TOTAL:
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) I$SUANJ
CFDATE
which emit haxardom.tr contaminants..defined by the Bay Area Air ? ii Y I
Quality Management District? BOILER-COMP DEE'OR 100,0(10 BTU)
��i J Yes n No JUL'1�-
ihave read the th&Si f.t materials requ.25505,MS33under Chapter 4.1 of BOILER-COMP(OVER 100,000 BTU) 1092
theerstandn HealthbSafetyCode, otcurrently have a Land,that ] 1x7s7
understand that ifthe building does not currently have atewnq that itkmy NEW RESIDENTIAL MECH. SQ.FF. CO
�. -
responsibility to notify the occupant of the requirements which most be met CO OY GUnuil 11 /
prior to issuance of a Certificate of Occupancy.
' Ownerorauthoriaed agent Date - ISSUED
T
OFFICE COPY