20576 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
..
Hulldia,Project Identification PERMITNO.
Building Address: 8�0 C
03 C A G J
76
Owner'sName: one: APPLICA F[ON SUBMIT IAL NA-717-
vilf—ovy, CITY OF CUPERTIN613UILDING DIVISION Iq
Contactors Name: Lie.No: APPLICATION /PERMIT — ( D
a j / J BUILDI GGRLECTRICAILPLUMBING-MECHANICAL CATEGORY CONTROL D fJ-Qa
Architect/Englneer. Lic.No: (�
QTY ELECTRIC PERMIT .FEB ! BUILDING PERMIT INFO
Address: PERMITISSUANCE a QD
JLLxJ
ry
LICENSED CONT d under
DECL.of Cha N
I hereby ef.7000)tf Dl lig Sof under presand Pm ChapteCode,amrnc APPLIANCES-RESIDENTIAL - ]OB DESCRIs7'ION
ingwlt s1.fun7recLa Dlvfect. (the BualneeiandPro/easionaCode,and my N
license alntull fo and effect PANELS •\D /I ��
license Class �. .Lk.N S/C 7/S3 - (f .
Date--,f/ Con[aRor /.'( I N�r�a7UP TO 2DO AMPS
ARCHITECTS DECLARATION 201-1000 AMPS
pQ?re0 O I understand my para shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA 5/SQ.FT.
F, Licensed Professional SIGNSELECTRICAL 1 97 7t, 9Z:
GGG p45�m OWNER-BUILDER DECLARATION l
IherebyafOrm
that lam exempt fromthe Contractorb Licence Law(orthe SPECIAL CIRCUIT/MLSC
o pp following reason.(Section 70313,Business and Prufessbna Code:Any tty or
Fz W county which requires a permit tocomtmct,alter,improve,damolah,orrepair TEMP.METER OR POLE INST. '
q� '� any structure prior to its issuance,also requires the applicant for such permit to POWER DEVICES
F file a signed statement that he is licensed pursuant to the provisions of the
Contractor's License Law(Chapter 9(commencing with Section 7000)of DIv1- c VALUATION
ani SWIMMING POOL ELECTRIC
the 3 of thebasis
thealleedexamptim. AnyCode)orthat lation f exempt therefrom and a,_ t% a vO
<, the baafor the alleged sects the
a Any t violation of Section no m by anyle OUILETSSWITCHMFIXT URES G (/e��ye 0
applicantudfora permit subjects Ne applicant to a civil penalty of not onretlun I S$/�
o five hundredddarshepr. e
WWW �I,ac owner of the property,or my employees with wage as their sole I�EW A IiNmAI ELECTR SQ.FT. TYPE CONSTRUCTION
5 G compensation,wBlduthe work and thestruture isnot Intended or offend for . - ,l"
9O wle(Sec 7614,Bu.W.$rut Profeaiom Code:The Contract- License Law
does not apply to an owner of property who Wilds or improves thereonfSnd,i"'c
5.. ', OCC.GROUP RFS UNITS
whodoeesuchwornet lot ltorthraugh hleownemployee>pi vWed that �y�
improvements are not int ended ororq�clusively
orsale.[4'howe,'eT,thebuildingor �,v TOTAL: 21VW
Improvementissoldwlthlnomyearpltbry ihe09 bullderwlll have
II L4urden of proving that he did ndr;imi'rovee fa•`purpose of sale.).)Q'I '3 P N PERMIT FEE FLOOD ZONE APN'
LJ L as owner of the property, mntrating with Ikenxd. PERI ANCE
contractors to constrotthe project44,'Businem and Professions Code: -
Contractor's Licence Law doesply to an miner of properly who
builds or Improves thereon,and who cyntraN:for such! Wjects wiili a Z ALTER-DRAIN&VENT-WATER(EA) m 'FEE SUMMARY
emir-dor(a)1lcensed pursuant to the Contra"to Llmnm LN, Y BACK FLOW PROTECT.DEVICE
LJI em exempt-under Sec..._.__.__°7 .U_.�Bk P C for this reason '
Owner NAY R
Dale DRAINS FLOOR ROOF,AREA,COND. Lt (03 SANITARY Y— N= -
WORKMACOMPENSATIONOECLARATION RRCRTa
rt,[hereby affirm that I have a certificate of consent to selfdnsure,m a FD(TURES PER TRAP SCHOOL TAX Y _ N
certificate ofWorkeri Compematlan lmura ex,or a certlfled copy thereof(Sec. RRC®rhR
3800,Lab GAS EA,SYSTEM-1 INC40UTLETS PARK FEERECEIPT .
PolicyM - �0 f 1 Z.T L GAS EA.SYSTEM-OVER4(EA) BUILDING DIVISION FEES
Com anv Ta Fi•.. r
�certlned copy a hereby fumiehed. GREASE/IND USTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy is filed with the city Inspection divialan. V
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAIT PAID
COMPENSATION INSURANCE SEINER SANRAAYSITJRM EA 200PT 'Date Recei t#
(This setlon need not be completed ifthe pamot isforone hundrad dollarsdolla
(5100)or le®.) WATER HEATER W/VENT/ELECTR - ENERGYFEE Y_ N ' o IV
I certify that in the performance of the work for which thin permit b asued , V
I shall not employ any person in any manner so as to bemire subject to the WATER SYSTEM/TREATING
Workers'Compensation Uwsof Callfomia.Data PAID
Z Applicant t NEIN RESIDENTIAL PLMB. SQFT: Date Remi t#
Z Q NOTICE TO APPLICANT:If,after making this Certificate of Exemptlon,you
should became subject to the Workers''Compewtloo provb t of the Labor .. .TOTAL:
� tq Code,you must forthwith comply with such provisions or this permit shall be ULDIN d�•
deemed revoked. .M
W.C CONSTRUCTION LENDING AGENCY '�T 2,CXJ SEISMIC FEE
a I hereby affirenthat there Is a construction lending agency for the pertomrELECTRIC FEE e00
7 Z ante ofthe work for which this permit is Issued(Sec.3097,Civ.C.) • TOTAL: ZI•(;�
02 Lenders Name PLUMBING FEE
_ IL+ F Leader's Address QTY. `.MECHANICAL PERMIT . FEE' . MECHANICALFEE a[�1
OW1odifythat I have read this application and state that the above Information
1 scomet.I agtmto comply with all city and county ordinances and state laws PERMIT ISSUANCE Z(0� FEES PAID:
>. relating to building construction,and hereby authorlu representatives of this
I— Z city to enter upon/lfe above-mentioned property for Impaction purposes. ALTFRORADDTOMECH. 4f-✓ Date "Receipt#
_ (We)agree to save,indemnify an d keep harmleas the City of Cupertino a e
against lWbRitks,udgments,costs and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City in comequence of the granting of this permit.
' AIR HANDWNG UM'I(OVER I0,000CFM) CONSTRUCTION TAX
J/ CONSTRUCTION.TAX PAID:
SI nature of AppBantARDOator Date EXHAUST HOOD(W/DUCT)HAZARDOUS MATERIALS DISCLOSURE P '
Will the applicant or future building oavpant$mre or handle haaardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Charter 9.1 2,and the
Health and Safety Codes cm
25532(x)? HEATING UNIT(OVER 166,000 BTU)' TOTAL:
❑Yes cm No
WW theepplicantorfuture Wilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANC&DATE
which'emit hazardous air comaMwnta as defined by the Bay Area Air
Quality Management District? BOILER-COMP OHP OR 100,IXD BTID' � .�� I()n0
'?hYs tRNo 13x1
a Bread the Eau ous materlaa requirements under Cha pier 6.95 of BOILER-COMP(OVER 100,000 BTU)
the G1vernia Health k Safety Code,Sections 25505,25533 and 25534.1 {
understand that if the building does not currently have a tenant,that it is my NEWRESIDENTIALMECH. SQ.FT. fn'4,j Int U"Lrmfints,
ropoexibility to notify the occupant of the requirements which moat be met 4CJ 0 b" ,
prior,toissuance
/of a�rti/kate of Occupancy.
,,
OWh r or authorized agent ate - ISSl1EDBY:
TOTAL:
OFFICE COPY