19511 APPLICANT TO FILL IN INFORMATION WITHK ES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Baumng Addams:
C a9^t5r
#.h,,r.9
Phone: qCe"^7/ll7{_ CITY OF CUPERTINO-BUILDINGDIVISION
- LINOAPPLICATION If PERMIT
[„�J1 BUILDING-ELECTWCA PLIIMBINGMECHANICAL CATEGORY CONTROL N�1/Engineer. 'Llc.No: ll
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:
PERMITISSUANCE g ❑ �[)I ❑ ❑
LICENSED CONTR under eDECLARATION jog
I hereby
th Sb ffirmthat]am.1.3 licensed fth.Bu nmandsol Chapter 9(commen AIPPLIANCESREEDENTIAL JOB DCSCRIPTfOK
(ngwlthSeMon7000)of Dlvtslon Jo(theguanessandlPmfesalonsCode,and my
ILI lmrue Is In full( and c.11 4 a5 PANELS 1C1 /D�
Date Class /OLich " ,JI C/
Date ContractorUP TO 2DOAMPS
ARCHITECTS DECLARATION 701-IMOAMIS
qwq1� CCO Iand retardmyplansebaBbeuaed u publicrecords. OVER1000AMPS SQ.Fr.FLOOR AREA $/SQ.FT.
E d Llomsed Professional SIGNSELECTRICAL
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MLSC
z p. I hereby afflrmthat l am exempt from the Contractors License Law for the
C) —q following reasmn.(Saction 7031S,Business and Professions Code:My city or
rq cauntywhkhmquW apermlttommtact,alter,lmprove,demotish,orrepair TEMP.METER OR POLE INST.
anystmeture pricr to its beuance,also requ]res the appliant fur such permit to
<� file a signed statement that he is licensed Pursuant to the ProWlmxl Of the POWER DEVICES
Owl Contractors License Law(Chapter 9(commencingwith Sect]on701D)ofDivl-
�O�p eI.n3ofth.Buannsand Prof.ab Code)orth.th.iemmptthemfmmand SWIMMING POOL ELECTRIC VAL TION
the basis for the alleged exemption. Any Violation of Section 7031.5 by any
<R OU71'E7SSW[7'CFIE4'FT7('TURFS
applIantfora permit sub*U the applicant to a civil penalty of net mon than
O —/�//a- Q
vundmddollars($500). NEWRESIDENTIALELECTR SQFC. STO , TYPECONSTRUCTION
z�n I,as owner of the property,or my employees with wages as their sole •-�
C < compensation,wBldo the work,and the structure is not intended or offered fortr�• 6l
$ q sale(Sec 7014,Business and Pro(®lora Cade:The Cantnctore License hw
does not apply to an owner of property who builds or Improve thereon,and OCC.GROUIP RES.UNITS
who does suchwmk himaetforthrough hbawn employee,provided thetach
improvements am not intend.dmoffered forsale.If,however,thebullding w TOTAL: ��
Improvement hsold within oneyearofcompletiorytheowner-bu0derwlllhave
1tILIjurden of pmving that he did rot Wild or Improve for purpose o/sak.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
u L as Owner of the property,am exclusively mntractlng with Ilcenxd PERMIT ISSUANCE
ronlractoes to construct the project(Sec.7099,Business and Profesimns Cade:
The Contractors License Iwo doe not apply to an owner of property who
bunds or Improves thereon,and who contracts (or ALTER-DRAIN 4 VENC-WATER such ptulecte with (EAI
cgatractu(s)licensed pursuant to the Contractor's License Law. BAQC T E FEE SUMMARY
IJ I am exempt under SmB h P C for this mason
DRAIN FI&X'ZpOF,ARBA; N0. S TARY Y N
Avner Date 1 RECEIPT M
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a comfican of consent to self-Inure,w aPEcTURkrPERIRAIL v i00L TAX Y_ N_
certlflWeo(Workers'Comper tionimunnmoracertlfk copythereof(Sec. RECEIVE
3800,Lab C.) C EA.SY NC_4 P RK FFR Y N
Policy Y _ _ RECEIPT R
Com any G FaA-SYSTFMOVER 4 IRA) BUILDING DIVISION FEES
[�Ce ed copy b herebydwith the
city GREASE/INDUSIRI.WASTE INTERCEPTOR PLANCHECK FEE edIV6
ertlBed copy V pled with the city inspection divided. /S b
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID / /d TA
COMPENSATION INSURANCE SEWER-SANITARY-b'NRM EA 2WF1. Date Recei t#
(This stolon need not be completed lithe permit b for one hundred dollar
($1I0)wl th WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certify that N the performance of the work lorwhicb this permit is issued, —
I shall not employ any person In any manner so a to become abject to the WATER SYSTEM/TREATING
Workens'Compensation hors of Ull(omla.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Recei t#
Z O NOTICbecomeE TO APPLICANT-.*cttote,after
arkers'Com er ationorti Pre is Exemption,you
I" shouldma..efbhe ache Warketh.ohensati ..tthlonsofthehbor TOTAL:
CCN Code,ymu mast lorthwlth comply with each proWkns orchis peaNt shall be
LLI >_ deemed revoked.
CONSTRUCTION LENDING AGENCYEESEISM
d Iberebyaffirmthat there iso construction kndinga,,ncy forthe perform- ELECTWILDING ECE
IRIC FEE
Z anw of the work for which this permit is issued(See 3097,Civ.C3 TOTAL:
U O boder.Name PLUMBING FEE
LL F hnder.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Iwrtifythat l haveresdthisapplical]ors and statethat theaboveinformMlorn
Iscore
rat.I agree to comply with all city and county ordinances and nate laws PERMIT ISSUANCE FEES PAID:
>. 0.W relating to building construction,and hereby authomes,repecas antives of this
(— Z .city to enter upon the above-mentioned property for WpMlon purposes. ALTERORADDTOMECH. Date RCCCi t#
_ (We)agree to save,IndemN/y an d keep harmless the City of Cupertino P
against liabWtkre,Odgments,eas and expenses which may In any way accrue AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL'
against said City In consequence of grant ORO this permit.
AIR HANDLING DFIrr(OVER 10,BD0crM1 CONSTRUCTION TAX
XSignstureof Appliant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant store or handle hazardous HEATING UNIT(T0100,000 BM Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Healthand Safety Code Section75532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: Q
I�1 Yes 0 No
Ty ill the applicant or future building occopant use equipment or devices VENTILATION FAN(SINGLE RESIDE ISSUA
which melt hazardous air contaminants as defined by the Bay Arca Air
llty Management District? BOILER-COMPOHPOR 100,000 BTU) F�.� �I 19Ps�
C L��Yes ❑No ss•��.
I havercad the bazallo. ma tedalsmquirementsunder Chapter6.95 of BOILER-COMP(OVM 100,0DO BTU)
the California Health k Safety Code,Sections 25505,25S33 and 25534. 1
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT. C'9a' �l/s.lr
responsibility to nobly the occupant of the requirements which must be mot `r V� � i
prior to issue race ofa Cert]llcate of Occupancy. ��--..�9_�' �4�aa,,..yy,� ,
Owner or authorized agent Data ISSUED OY:\11.1T�-9F"9'O Uxr_ke
TOTAL
OFFICE COPY