20519 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Pro'ek Identification 7 PERMITNO.
Building Address: /"1 O n
e G VM
wmn am: one: APPLILA 11 ,
L� l�llRl) CITY OF CUPERTINO-BUILDING DIVISION n
cnntadnr.wm: ' APPLICATION / PERMIT
Z gUfLDINGELECIRICALPLUMBINC-MECHAMCAL CAT GC)RY CONTROL#
Amhlted/Englnec Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PER IT INFO
Address$� ,�� �j•.#� ' I PERMITISSUANCE �'a ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby Affirm,that l am licensed under provlsloos of Chapter 9(marcome, APPLIANCES-RESIDENTIAL - JOB DESCRIPTION
Section 7(100)of Division 3 ofthe Busio#ss and ProfesalonsCode,and my
1.in fuOS � PANELS /
LirasseCWm Lc# 1 �
Date Contractor sat IVY--
DEC RATION 1_ 1 201-1000 AMPS
NO O I understand my plana nhalibe used as public records. +BWiR-IBBB'/tlrt73 V ✓ SQ.FT.FLOOR AREA S/SQ.FT.
ned Professional LceL
6 IOWNER-BUILDER DECLARATION n a SPECIAL CIRCUIT/M15C
Zy, I hereby afRrmthat i am exempt from the Contractor'sLicense lAw forthe
op following«soon.(Section 70315,Business and Professions Cade:Any city or
Oy TEMP.METOt ORPOLE INST.
p4 countywhkk requbesapermitromrutruct,altep lmpmve,demalbh,oc repair
$$$ anystmu mpriortolbbauame,aborequlmlheappllantfmmchpemdtto (!OWER DEVICES
"a1 Me a signed statement that he b licensed pursuant to the provisions of the
Ii
3µ Contractor's License law(Chapter 9(commencing with Section 7000)of Divi- LELECTWC ,i VALUATION
SOS slon3 of the Buslnesaand Prdemians Ccde)mthat he besempt therefromand
the blab for the alleged exemption. Any Notation of Section 70115 by any
aappBantim-pemdtaubjecbtheappgcanitoadNipenslty ofna.m than to OUTLETSSWITCFDSFATURES
five 1,..o owndoler
Itheprrs . NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPECONSIRUCTION
❑e ea owner of the property,or he employees with wage as thele dole —
a mmpens 7044,willdoBusiness
lume he sand kandthes Code:reEs he C intended or offeredLaw ( AzAsVI•r �"
O art(Sec. ppy to ainowand Pro(emrons Code:The uilds orimpdars Lt.roves hemeLaw
$$ e,and
whodocdoes not auch torn owner of property who nemporimp provided that such
1 V'� OCC.GROUP RIS.INTER
whodoementswork him eVort or offered
Maow aleph oweer,thedthatsuch
Improvementeared noel withinded one earofred(male.If, owner-tithe building or TOTAL: Z�
Improvement is sold withlnoneyearafcompldlon,iheowner-W 0derwlll have
tlW-tturd en of proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD 7p(E APN
u L as owner of the property,am exclusively contracting wish Ikensed Pr"IT ISSUANCE
contractor to mmtmd the pmjed(Sec.70K Business and Professions Cade:
The Contndor'n License law does not apply to an owner of property who ALTER-DRAIN A,VENT-WA [FA)
Wilde or Improves thereon, and who contra for such ;upjeda with a FEE SUMMARY
a)licensed pursuant to the Contractor's License Law. BAIX FLOW PROTFLT. EVICE
LI I am exempt under Sec. B k P C for this reason
DRAINS R ROOF,A SANITARY Y N
. Owner Date RFLEE'C Y
WORIC1tAN COMPENSATION DECLARATION
01 hereby affirm that I have a motifican,of consent to c"thsure,ora I7X7URES-PER SCHOOL TAX Y N
cekl0cat:o(Werken'Compenastlon Wurancema cekRled avpythereof(Sec. RECEE NN
Policy# CO CAS F.A. NC. Ef5 PARK FT]i Y_ N_ -
Poon N RECEIPTp
Com any C�'�'� "O BUILDING DIVISION FEES
�CekiOed copy is Nhereby thcity furnished. GREASE/WDUSIRI. EP R PLANCHECK FEE
Ceked copy b(filed withhthe city inspedlan division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY STORM EA Date Recei t#
(Ihlssectlon need not be corepleted lithe permit la forom hundred dollars
T/FI rr.I.R
' Imfttfyklfy that rothe perfomunceofthe work(orwhkh this permit lebmed, WATER HEATER W/VENENERGY FEE Y N
I shall not employ any person in any manner so as to bemm subjed to the WATER SYSTEM/TREATINGWorkers'Compensatlon Laws of California. Date PAID
Z N'O7licant
TCETO APPLICANT:ILafter makingthb CertRlate of ExempOoryyou NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
should become..1,Pci to the Workers'Comperualion provisions of the Labor TOTAL:
V) Code,you at forthwith comply with such provisions or this permit shall be BD
W > deemed revoked.
CL F2 CONSTRUCTION LENDING AGENCY SEISMIC
IberebyafRrm that there Is a consbudlon lending agency for the perform- ELE GFEE —r 00
D Z an.of the work for which this permit is bsued(Sm.3097,CIv.C.) TOTAL:
0 O Lenders Name PLUMBING FEE
U. F Lend.e.Addma QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW ImAifythatlhave¢adthbappliationand statethatthe above information -
1 incorrect.l agmtocomplywbhall dtyand countymcli.an....dgets laws PERMIT ISSUANCE FEES PAID:
>. relatingtobullding commaction,and herebyauthorlexrepresentattvesofthis
1.. 2 city to enter upon the above-motioned property for inspection purpose. ALTER OR ADD TO MECH.
(We)agree to ave,indem ify an d keep harmless the City of Cupertino Date -Recei t#
V against liabllitles,jedgmenb,aortaand rape..which my lnanywayamrue AIR HANDLING(NIT(TO 10,000 CFM) SUBTOTAL'
signature
Bald City In..ago erm of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applant/Contractor - Data DGIAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fu us building occupant store or handle hazardous 1 IFATING UNIT(TO Ifie"BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the �#�aa/��
Health and Safety Cade Section 25532(002 HEATING UNIT(OVER 100,000 BTU) TOTAL .7,00
❑Yea No
Will/he appllanl mut urebuildingompanluuryuipmnt ordevlms VENTILATION FAN(SINGLE RESID) J)S$jU pDATE
which emit havrdous air contaminants.,defined by the Bay Area Air- F' /ylL/
aLjallity Management Dl❑sMd7 BOILER-COMP DEEP OR I00,IXD BTU) �3 y /�
Ihavice read the hazallouaomaterials mqulrementsunder Chapter6.95 of BOR-ER-COMP(OVER 100,000 BTU) JUi4 0 V 199U
the California Health 6,Safety Code,Sections 25505,25533 and 25537.I
undmta od that if the building don not currently have a tenant,that It is my NEWRESIDENTIALMECH SQ.FT. n '
responsibility to notify the ompant of the requirements which moat be met Is:c ..L/suAprN.nn
priortoissuanmofa Ceklficateofocmpancy. L HL Y L fta
Owuer m authmized agent Date ISSUED B
TOTAL:
OFFICE COPY