21994 II APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Build ing Address:ilding Project Identification P TN21994
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CITY OF CUPERTINO-BUILDING DIVISION
ame: Lie.NaAPPLICATION /PERMIT
Bines`. - Lk.No: BU(LDINC-ELECTRICALPLUMBINC-MECHAMCAL CATEGORY CONTROL p
QTY ELECTRICPERMIT FEE BUILDING PERMIT INF
Address:
PERMITISSUANCE ❑ ❑ ❑
LICENSEDCONTR under rDECLARATION
[herebyf..70 thatlamlkensed 3ofthe ur nessslomoffe aonsCodc mens APPLIANCESRESIDENTWL JOB DLSC ON
Ingweh Sedion 7000)of Dlvislon3ofthe Buslnneand ProfaaloneCode,and my
crenae is In mu and erred. PANELS LIP TO 200 AhIPS
�I�'nC/'
License Cla Lk.p�
Date Contra r
ARCHITECTS DE ARATIO 201-1000AMP5
tqu OC I understand my plans shall be used as public m"ds. OVER 1000 AMF5 SQ.FT.FLOOR AREA $/SQ.FT.
E odE Licensed Profeniorml SIGNS ELECTRICAL
6 OWNER-BUILDER DECLARATION SPFGIALCR2CU[T/MISC
I hereby affirmthaf I am exempt fromthe Contractor's License Law for the
following reason.(Section 7031.5,Business and Professions Code:M d or
O r• y city TEMP.METER OR TOLE INST.
p� nystm which pr orirestai pe nce,aromquitrad, lter,lmplinntf such,orretto
g any arocture statement
a is aleoeed pursuantt the forautomof It a POWER DEVICES
file a signed statement that he b Ikensed pursuant to the provlslo�u of the '
Wb3i„ Contractor.License Law(Chapter9(rommencing with Section 7000)of Divi- SWIMMING IY30L ELECTRIC
SOS emn3ofthe euelnenand ProfeniomCode)orthat hebexemptthercfromand VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLEISSWI'TCFILSFIXITJRFS V
G applicantforapermii.object.theapplicanttoadvllpemltyo(nM=mthan
f(vehundred dollars($50). NEWRFSIDENTIALELECTR STORIES TYPE CONSTRUCTION
�n I,a.owner of the roe SQFI.
property,k,a or my employees with wages r thele sole
compensation,K will Busdoth.work and toes Codure b rCContractor.
Intended or offered for
q sale(Sec. pply to alnowerf property who
uild@The Contractores License Law
don nonsuch torn owner ofpropertywho nem oyes,pro provided
that
Ruch OCC.GROUP RES.UNITS
and
who doessuch am not himself
dee°rough hisowne.If,ho es,p r theb that such
Improvementsaredwith node tuff mplati n,the owe`-bull building or TOTAL•: '
Improvementforavi gtha on did ran
rim thee for
rposerwiilhave
t rrlen ower of the tt�e erty,a build orlmp contra ting with
°rook.). kTY.
PLUMBING PERMIT FEE FLOOD ZONE APN
L ae owner tr6d a project Se exclusively ess and ro with IiremedPERMIT ISSUANCE
contractorsm rortesth then,and(Sec.7044,Raciness and Pio pj eta Code:The Contractor's License law don not apply to an owner of property whoALTER-DRAIN&VENT-WATER(EN
WEda or improve tPursua,and who tratrarn for such ptojecb with a FEE SUMMARY
ctor(s)Ikensed tunderuant to the Contractor.Lk&PLaw. BACK FLOW PROTECT.DEVICE
I am exempt under Sea B&P C for this reason
e ae DRNNS FLOOR ROOF,AREA,GOND. SAMTARY Y NRECEIT p
WORKMAN COMPENSATION DECLARAION pIX'IVRES rER TRA` SCIdOOL TAK Y_ N-
01 1Tq i LIE FEES
hereby affimt th3CLheve a req fi,aita of Imawnt to.elf-Insure,or aFre.
tateo('Norken'Compe a nlmuranre oramrtlfled copy thereof(Sec. GAS EA.SYSTEM-]INC.40UTLETS RFLEI'fp1 'L^J PARK FEE Y_ N—
Cooman GAS EA.SYSTEM-OOVER DING Tp
LJ Y - BUILDING DIVISION FEES
Bed copy Ls hereby mie city
GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
� erllf ed copy Is filed wl the dty lmpection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRP
COMPENSATION PAJD
COMPEON INSURANCE SEWER-SANITARY-STORM EA 200F1' Date Recei t#
ffhissectiDn need net be NSATI lithe permit bforom hundred Motion
($100)or len.) WATER HEATER W/VENT/fl.ECTR ENERGYFEE Y N
I rectify that in the performance of the work for which this permit is Issued, —
I shall not employ any person In any runner m as to become subject to the WATER SYSTEM/TREATING
Workers Compensation Laws of California.Date PAID
z Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
Z O should ETON'PLIDAMthe orkem'fter komparing thin Certificate is Exemption,you
should become subject to the Workers'CompemaHon s or thin
of the Labor TOTAL:
N Codayou
revokeforthwith comply with such provisions orlhLs permit shall be BUILDING FEE
darned revoked.
OW. C CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there Is a comtruction lending agency forth.perform- ELECTRIC FEE
Z ante ofthe work for which this permit b Lowed(Scc3097,CIv.C.) TOTAL:
V O lender.NamePLUMBING FEE
LL ~ - Leadcr.Addea. QTY, MECHANICAL PERMIT FEE MECHANICAL FEE
O W Inrtifylhatl haveread this applimtionand Matethatthe above information
1 Iscorrect.I agree to camplywith all city and roan oNinancasand elate law. PERMIT ISSUANCE FEES PAID:
N relating to build comtructlon,and he b uth M representatives ofthl.
)— Z city to enter nth above-menti° ky or Wpection purposes. ALTERORADDTOMECH.
— (WRlebwt�k,
a to ,Indemdfytgr..�M�g:�thmi
I, the Cli of Cupertino Date Receipt#
agers' dgroents, may In anyway accrue AIR HANDLING UNIT(T010,000 CFM) SUBTOTAL:
agalnnrons yuepermit.
AIRHANDLING IIMT(OVER 10,000CFM) CONSTRUCTION TAX
gSig to p k t act Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
H Domb MATERIALS DISCLOSURE
Will the appll oheC IlldlM occupant storeorhtrr9.haaaedom HEATING UNIT CTO 100,000 BTU)
Healtha and
deft d le-h ppppppppppppsssarr��ttttlno2(.)?n al Cade,Chapter 9.12,and the Date Recei t#•
Health and Safety Cod25532(a)7 HEATING UNIT(OVER 100,OOD BTU) TOTAL:
Yea N
Illthe applicant (uturVm1n,building occupant use the B.yentordevices VENTILATION FAN(SINGLE RESID) ISSIR,J�I TE
whkheMaraurdous au cont mote as de(Ined by the Bay Area Alr
Quality Management Distd o BOILER-COMP OFI'OR 100,0008TU) ny3
I7—J Yea APR 4 � tl
have read the h amaterlala requirements under Chapter G95 of BOB.ER-COMP(OVER 100,0008TU)
the Glifom alih&Safety Co Se dions25505,25533and255M.I
understa th if the build gdo not mrrentlyhaveatenant,thatitlsmy NEW RESIDENTIAL MECH. SQ.Fr.
_resp. ility onotlfyI tot th$$..rRryirementa which at be
prior nu reo(a o(OcN'pancy.
•� r or au or age t to
TOTAL: ISSUEDBY: a
OFFICE COPY