20843 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proed Identification PERMIT NO.
BnI lnZd - rCr-� — - 20843
/ ro a : �-� CITY OF CUPERTINO-BUILDING DIVISION
e:�
is ors Name: Lie.No: APPLICATION / PERMIT
/• 10 BUILDING-ELECTRICAL MUMBINGM IIAMCAL CATEGORY CONTROL 0
Architect/Engineer. Lie No:
Q'[Y ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMQTISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Thereby affirm that l am licensed under provisions of Chspter9(mmmene APPLIANCES-RESIDENTIAL JOB DESCRIxf10N
Ingwlth Seciion7000)of DlvtMon3ofthe Budn sand ProfesslonsCode,andmy 'l a
license le In full fo and effect. / PANELS 0a/ I (�/!i M•/eul
License as LIc.N /.-.
Date Contractor I /.n
ARCHV=' RATI N 701-1000 AMPS [/J
qq��uu M ZO I understand my plans shall be used as public remade. OVER IOOO AMPS SQ.FT.FLOOR AREA a /SQ.FT.
k Gmnsed Professional SIGNSELECTRICAL
OWNER-BUILDER DECLARATION
SPECIAL CIRCUIT/MLSC
7 F., I herebyafflrm that l sin exempt from the Contradorb License Law for the
F.
following reason.(Section 703 1.5,Business am Professions Code:Any city or F� muntywhlch requlresapermittomns[act,alters improve,denmllsh,orrcpatr TEMP.METEROR POLE FIST.
<ys� anystruentre prioatoits baan6e,a6orequireatheappBontfor such perndtto POWER DEVICES
R m file a algned statement that he is limned pursuant to the provisions of the
Ole Contnctoes License Law(Chapter 9(mmrrendngwith Section 7000)ofDivi.
�OS Mon3otlhe BuMnessand Profmi mCode)orthathelsexempttherefromand SWIMMING IDOL ELECTRIC 0 yALUg'1'IfaN
<, the basis for the alleged exemptlon. Any violation of Section 70315 by any OUTLETSSWHCHIESFIXTURES (�/) g•}L
applianot m
rt fora permit subjectstheappllcant to a civil penalty of nore than 111
illimdred dollars(S500), NEW RESIDENTIAL ELLCTR
6SQ}T. WES TYPE CONSTRUCTION
I,as owner of the property,or my employees with wages as their role
�7a wmpcn&atiory willdo the work.and the stmmue isnot Intended or offered for
' ❑ aie(Sec.7064,Bueiruresand Profesions Code:Ths Contradars Llmnse Law
domnotapplytoan ownerof property who bulldsorimprovesthereon,and OCC.GROIIIa RFS UNITS
EES• whodoessuchworkhlmeelforlh=ghhisownempicyeea,provldedthatmch
Improvemems are not intended oroffered forsale.If,howevegthe building ce TOTAL:
improvement tssoMwithinoayearofeompletlorytheavner brullderwRlhave
t4e.kn rden of proving that he did not band or Improve for purpose ofeale.). QTY, PLUMBING PERMIT FEE
U L as owner of the property,am exclusively mntra&tng with licensed FLOOD TONE APN
metacmm to mnstruR the Project(Sec.7014,Buslneu and Profeslorm Cody. PERMIT ISSUANCE
Ile Contractor's License Law does nu apply to an owner of property who -
builds or Improves thereon,and who contracts for such pipiects with a ALTER-DRAIN&VENT-WATER MA)
cgatlacto(s)licensed puauant to the ContradoYs License Law. FEE SUMMARY
U I am exempt under Sec, -B&P C for this rcawn BACK FLAW PROTECT.DEVICE
OUTS I OF FEES
DRAINS.FLOOR,ROOF,AREA,GOND. SANITARY Y
Owner DatSANITARYN_RECOPI'N
WOR RMAN COMPENSATION DECLARATION pIXTURES PER TRAP SCHOOL TAX Y N
QI hereby affirm that I haus a mrtlfkaa of consent to self-Insure,ora RECEIPT I
certificate ofWorMen'Campenutionlosurancamacertlficd copy.lheno((Sec.
GAS.EA.ESYSTEM-1 WC4 OUTLETS PARK FEE Y N
3BEO.Iab C.) 61o3(a
AING T M
Policy N GAS EA.SYSTEM-0VER 4(EA) BUILDING DIVISION FEES
cnm env__ ri
fled py ishereby PLANCHECK FEB
[PCe�I �cooramity GREASE/INDUSIRL WASTE INTERCEPTOR
ertlfled ropy is filed with thee city inspection division.
CERTIFICATE Of EXTIM PTION FROM WORKERS' GREASE-TRAP PAID
COMPENSATION INSURANCE SLZVQLSANTTAItY-STORM FA700Ef ' Date Recei t#
(Thissedoo need not be completed tithe permit ls fororm hundred dollars
(S100)oalese.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
I mrtifythat in the performance of the work forwmch this permit Is Issued,
I shall not employ any person In any manner an as to become subject to the WATER SYSTEM/TREATING
Wwken'Compenaattonlawsof Callomla.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQFL t#Date Rem
Z O ND77CE TO APPLICANT:U,after making this Certificate of Exemption,you
shmld become mbpat to the Workers'Compeoution provisions of the Labor TOTAL:
fq Code,you moat forthwith comply With such provisions or this permit&hall be BUILDING D
W 7 doomed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE S
a I hereby atfirmthat there is a mnstruRlon lending agency for the perform- TOTAL: ELECTRIC FEE
Z anm ofthe Work forwhich this permit isismed(Sec.3097,CIv.QO O Lender.Name PLUMBING FEE '
U. F- L.cndera Addres QTY. MECHANICAL PERMIT FEE MECHANICALFEE
OW l certilythat l have read thlsappiicatlon4m tlatethatthe above information
a Ism=&.lagrceto comply with all city and munty ordinances and Male laws PERMI7ISSUANCE FEES PAID:
} W relating to building mmtmmon,and hereby authorlu representatives of this
cit to entero n the above,mentioned for W ion ALTFAORADDTOMECH.
~ ? y(We)earm save,IndemNly an d property
the Inspection
of Cu pedmo Date ReceiPtk
V
against liabilities,Judgments,mats and expenses which may In any way acme AIR HANDLING UNIT(T010,f100 CFM) SUBTOTAL:
aga lost said City in consequence of the grant ing of this permit..
AIR HANDLING UNIT(OVER 70,000CFM) CONSTRUCTION TAX
Signature o(AppB AZ.A w Date
EXHAUST HOOD M/DUC'D CONSTRUCTION TAX PAID:
NA7ARDOUSDOUS MATERIALS DISCLOSURE
Will a the efload bylicant theC building a I Cooreorhter 9.havrdouathe HEATING UNIT(TO 100,000 BTU) Date ReCCf ig
material ate daRad by the Cupertino MuNcipal Code,Chapter 9.1 7,and the
FkaltM1aM Safety Code Section 25537(a)T HEATING UNIT(OVER 100,000 BTU) TOTAL:
MY. , f No
Will the applicant or future building occupant use equlpment or devices VENTILATION FAN(SINGLE RESID) IStAR40DATE
which emit hazardous air mntaMantl as defined by the Bay Area Air -
Q11.1fty Mawgument District? BORER-COMP OHP OR 100,000 BTU)
I__I Yrs ❑No BOILER-COMP BN) 31990
x Ihave read the haardou&materials rNulrements under Chapter 6.95 of AUG
the Gllfomla health&Safety Code,Sections 25505,25533 and 75536.I
understand that lithe building does not mrmntly have a tenant,that It is my NEW RESIDENTIAL MECO SQ.Ff.
responsibility to notify the occupant of the requirements which must be met City of rupp�iflo
prior to iseuanm of a Cer ificate of Ocmpancy.
Owner or authmimd agent Data ISSUED B
TOTAL:
OFFICE COPY