19764 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Praied Identification PERMIT NO. '
Building Address: 1 9764
. /020/ 91/89 P-D 8vg8 3
_ ner
a Name. Phone: p
Ap" CITY OF CUPERTINO-BUILDING DIVISION ( `�
cantrs a .NamL Q�' Llc.Na. APPLICATION / PERMIT l (f
BUfLDINGELECTRICAleFL MBINGMECHAMCAL CATEGORY CONTROL N
Architect/Engineer. ZGAMLk.No:
25 AW A A , A� QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address: /f H lfJl PFIWTISSUANCE El ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby aHtrm that l am licensed under provisions of Chapter 9(comment, APPLIANCES-RESIDENTIAL JOB DESCRB'T'ION
Ing with Section 7000)of Division 3 ofthe Budneasand Profmalm aCode,and my
Iiwnse is in fulljo d(ect. PANELS
License Chen (. Lk.R O M
Date Contractor�jJe 1
ARCHITTCI'S C A 1 N 201-IODUAMPS
mm'CZ I understand my pians shall be used as public records.- OVER1000AMPS SQ.FT.FLOOR AREA $/SQ.Fr.
k z U Licensed Professional S:GNSELDCTRICAL
<�6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MLSC
e, a Ihembyaffirenthat l amexempt fromthe Contractors License Law for the '
p following reason.(Ecalon 7031.5,Business and Professions Code:Any city or
p;Z�u9 cauntywhlchrequmaper ttowmtmMater,Impmve,demlbh,orrepalr TEMP'MEf1AORPOLEINST.
q� anyslr mmprtorto LUl ancgaiwrequirmtheapplimntfwsuchpor tto POWER DEVICES
f5 O file a signed statement that he h licensed pursuant to the provhloru of the -
�Qj
Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi.� VALUATION
� slon 3 ofthe Business and Profenlom m
Code)or that he is empttherefrom and SWIMMING POOL ELECTRIC
Q the bash for the alleged exemption. Any violation of Section 70315 by any OUTLETSSWIT'CHFSFIXTURES
applicant fora permit subjects theapplicant to a civil penalty of not mom than
five hundred dollars($500). r yj, r' S TYPECONSTRUCTION
$ NEW RESIDPNTTALE EC
r]I,as owner of the property,or my employees with wages as their sok
�Z compensation,wBldothe work and thestruenam lawt intended or offered for
F O sale(sec•7W0 B.gracia and Professions Cade:The Cmdract.e.License Taw
�$ does not apply to an owner of property who builds or Improves thereory and
^ whodoeesuchworkhlmseliarthmughhlsownemployees,providedlhatmch - O^^ RES.UNITS
Improvemrenlaare not Intended oroHered!weak.Ifhowever,thebulldingor TOTAL: �" 10
improvementhsoldwithlnoneyeare(compl&Wmtheawner-buBderwill have
tli,.tfurden of proving that he did malruild or Improve for purpose ofsak.). QTY, PLUMBIN PEA FOOD APN
U L as owner of the property,am exclusively cating with Ilcensd PERMIT ISSUANCE
to construct the project(Sec.7044,Business and Professions Code:
The Contncme.License Law don nn apply to an owner of property who ALTER-DRAIN kVENT-WATER IEA)
Wilds or Improves thereon,and who contracts for such projects with a FEE SUMMARY
cgB(Tador(a)licensed pursuant to the Contractor's License Law, BACK FLOW PROTECT.DEVICELJ I am exempt under Sec. B k P C for this crown
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y ' - N_
_
RECEIPT#
� WORKMAN COMPENSATION DECLARATION 11ItES
U11 hereby affhm that I have s mrtifiate of consent to self-Insure,or ID(7PER TRAP SCHOOL TAX Y_ N
RECEIPTNa
certRlatecdWorkers'Comperuation lruuamems terrified mpyth,.f(Sec. GAS EA.SYSTEM-1 INCAOUTLETS PARK FEE Y N_
3800,LabQ /� //J ra�a}�� a/'� RECm'1'M
Policy jl IS-l39�QJ J//f/G '�NV CAS EA.SYSTEM-OVER4(EA)
Ga ray - BUILDING DIVISION FEES
shtfled copy is herebyth the city GREASEANDUSTRI,WASTE INTERICEPTOR PLANCHECKFEE
ertlfied copy I.here with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER SANIARY-STORM FA 200FT Date Recti [#
Rhhaection need act be completed lithe permit h(Drone hundred dollars
($100)orless.) WATER HEATER W/VEM/'s.Fl FC.I.R ENERGY FEE Y_ N_
I certify that N the performance of the work forwhlch this permit la issued,
I Onil out employ any person In any manner w as to become subject to the WATER SYSTEh1/TREATING
Wmken'Compensatbn LawaofGBfomh.Date PAID
C• Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Rec'ei t#
Z ONOTICETO APPLICANT;If,after making thisCertl(Iate of Exemption,you
' should become subject to the Workers'Compemudlon Provisions ofthe Labor TOTAL:
N Cade you moat forthwith comply with such provisions orthis permit shall be
V � desmed revoked, BUILDING FEE
`LU CONSTRUCTION LENDING AGENCY SEISMIC FEE
C
1 Ihereby affirm that there is a constmctlon lending agency forthe pedormry TOTAL: ELECTRIC FEE
7 Z an ofthe work for which this permit is Issued(See 3097,Civ.Q
OOLc
nder'.Name PLUMBING FEE
LL F Lender'.Addre.a QTY. MECHANICAL PERMIT FEE Q
ANICAL FEE
OW Icedifythatl have madthisappliation and statethatthe above Information MECH
1 iscomed.I agree to complywlth all cityand county ordinances and state laws PERMIT ISSUANCE �,. uD FEES PAID:
relating m building construction,arad hereby antse
hortse reprentatives of this -
N city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH. - O�
? (We)agree to save,Indemnify and keep harness the City of Cupertino Date Receipt#
V against llabllltles,judgments,cosnandexpenses which may In anywayaceme AIR HANDLING UNIT(TO 10,ODO CFM) - SUBTOTAL:
against said City in consequence of the granting of this permit. CONSTRUCTION TAX
AIR HANDLING UNI'(OVER 10,000CF'M)
Slgoatureof Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZA R DOGS MATERIALS DISCLOSURE
Willtheappliant or fu building oavpanI wramhandl.h.rda., HEATING UNIT ITO 100,ODO BM Date Recti 1#
material as definedbythe pertlno Municipal Code,Chapter 9.1 2,and the
Health and Safety Cod a Ion 2S532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yea No
Will the applicant or lure Wilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE3ATE
which cost harardoua air m miasmas,defined by the Bay Area Air PAPQuality Manag.me. ! M BOILER-CAMP OHP OR 100,0(U BTU)
Yet I YN.
Ihave read the Fars ous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) in .1 't9yU
the California Health k SafetyCode,Sections 25505,25533 and 25530. I
understand that lithe building does not currently have atenanq that It h my NEW RESIDENTIAL MECH.. SQ.FT.
respwaibl tonctitythsoccupa of the requirements which must be met
prior to ance� mry.
Ai`caterP . r,;hl CR Cupertiam
Ownror aut�i horlud agentx� Date '1 _oA ISSUEDBY,
TOTAL: 0� Vwi
t OFFICE COPY