20805 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES—'USE BALL POINT PEN ONLY
Building Project Identification - PERMIT NO.
Bu waareav: ^ 4 8^0 0 5
G lT JS
CITY OF CUPERTINO-BUILDING DIVISION � .O-
comractu� j c� tloN APPLICATION / PERMIT
JJ ��0�06 BUILDING-ELECTRICALPLUMBING.MECTIANICAL CATEGORY CONTROL
Arehitect/Engiraer. Lie No:
_ � �e ) QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add--2;25q S ON\\ \�` PE7MITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(mannerc, APPLIANCESRESIDENTUL JOB DISC -TION
IngwithSMfon7000)of Divtsion3 otthe Budrassand Profetaon$CodCand my {�'r-��•Y-9�
Ilam le in lu and affect. O O6 PANELS IJV "' C'1 \
Limn k LIa" d V'f` T'' f�/
Date CenlraderUP TO 2DO ANUS
ARCHITECTSDECURATION OVER
AMPS
q�q�uu Ore pZ Iundentand my plans elan be used mpubB[records. OVER 1000 AMT'S SQ.Fr.FLOOR AREA S/SQ.FC.
k d Licensed Professional SIGNSELECTRICAL
<<.4 'OWNER-BUILDER DECLARATION
`1n SPECULCE(CUIT/Mise
pp fo0owing noon.election70313,Businer and Profnabra Code:My city or
02i.� TEMP.METER Oft POLE INSf.
PE cauntyeture requlresa issuamtomtuWcffiestheapmvent forsleh,urir
to -
any.tmcture priertstatement that
hat he Is Bernard pursuant t the provisch ions
ofpermit e POWER DMCFS
O � ills a signed datement that M V Bernard pursuant to the provlsiora of the
Contactors License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
NCO Mona ofthe Buslecasand Pecf sdora Code)orthat Loris exempt therefromaod - VALUATION
O$, the basis for the alleged exemption. Any violation of Section 70715 by any OUTLETS-SWITCHESEXTURES
subjects Oa
applicant fora permit subjethe applicant to a civil penalty of net nnre than v
Rv61,as o nerdelcafe he pr. NEW RESIDENTIAL ELECTR SQFr. STORIES TYPECONMUCT10N
�n I,sa owner of the property,or he employee with ween as there sok
compeee 7DKon,Business aill do the nd
and ionstroctureh wt Intended or tensoffered Lw
ak(nee TDM,to an ow and f property Cade:The Contractors hereon law
�B doss not
suchork owner dproughhisoWilds nemorimproves ers,prvidedmn,and OCC.GROUP RES.UNITS
who
ovdoes
mentsa ntintelf or dedoroffe dow formic.
If,however,the
buildthat ing
improvementsarenotintended earofco pletioe.If,however,theerwill have TOTAL:
improvement is mid wRhlnoneyearofcompldbn,the owner-bullderwlll have
ttr*rden of proving that he did net build or improve for purpose of wk.). QTY, PLUMBING PERMIT FEE FLOOD TONE APN
u L as owner of the property,am exclusively contracting wish licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code: l{a.
The Comncter's License law don not apply to an owner of property who ALTER-DRAW AVENT-WATER(EN
or Imprrns themos,and who contracts for such p(ojem with a
ctFEE SUMMARY
�gWTaor(s)earixd pursuant tothe Contractors License Law. BACK FLOW PROTECT.DEVICE
Lf I am exempt under Sec. B k P C for this reason
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECEBTN
WORKMAN COMPENSATION DECLARATION FD(NRpS,PER TRAP SCHOOLTAX Y N
Ell hercby'effbcertificate that I have acertificate a!consent to.e141nsure,m s RECEIPT N
anl0ate ofWorkeri ComperoaHon Insurance ora certified copy thereof(Sec. GAS FA.SYSTEM-1 WC4OUTLES PARKFEE Y_ N_
3800,Lab CJ
Policy RECEPfM
C.nnn - GAS EA.SYSTEM-OVER 4(RA)
Com any - BUILDING DIVISION FEES
Certleed copy is hereby furnished, GREASE/WDUSIRL WASTE INTERCEPTORPLANCHECK PEE
Certified copy k filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRIASETRAP PAID
COMPENSATION INSURANCE SEVER-SANTTARY-STORM F.A.200FT. Date RESc IN
(ThisseRlon need not be completed lithe permit is forms hundred dollars
(S100)mlen') � WATER HFATERW/VENT/ELIiCTR ENERGYFEE Y N
I nrtlfythat in the performance ofthewmk forwhich this permit is blued,
I shag not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation laws of California. Date PAID
O Z Applimnt NEW RESIDENTIAL PLMB. SQFT. Date Recei tN
z NOTICE TO APPLICANT.If,a(ter making this CertBlate of Exemption,you
should become subject to the Workeri Compensation provisions of the Labor TOTAL:
N Cede,you=at forthwith comply with such provlslora or this permit shall be U l'p
W > dremed revoked.
C CONSTRUCTION LENDING AGENCY SEISMIC FEE
IL Iherebyal0rmthat there is a construction lendingagency for the perform TOTAL:
U CD
ELECTRIC FEE
7 Z an a oftheworkforwhichthia permit hbsued(&c.3097,Civ.Cd Z•a
O lender.Name PLUMBING FEE O,6D
IL F UrAursAddens QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U Imrtlfy thatl havereadthisappliation and siatethat theabovelnformation
O W. lammed.I agreeto comply with all dyand man ordlnanceund state law. PERMIT ISSUANCE FEES PAID:
>- a relating to building construction,and heremImsentatNes of this
F N dtytoenteru ntheabove- pertyf ins Ion purposes. ALTER OR ADD TO MECH. .
Z (We) to ve,Ind fy A p ha he Cityof Cupenlno Date Recei t#
U agal ks' 8. ,ro expen ichmayinanywa Cerus AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
a ad con ! e this pnmit- — -
AIR HANDLING UNIT(OVER 10,000cFM) CONSTRUCTION TAX
S)f6ldmofAppB t/Co or tc EXHAUST HOOD(W/DIKT) CONSTRUCTION TAX PAID:
NALtRDOUSM ERIALS DISCLOS E
Will the applicant or future bu Ing arvpart store or handle havardous HEATING UNIT(10 100,000 BTU) Date Recei tp
material as defined by the Cupertino M.Wdpal Code,Chapter 9,17,and the
Health and Safety Code Section 75537(a)T HEATING UNIT(OVER IO,"BTU) TOTAL: �ItS
r-1 Yes u No
Wlllthe applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) IS$QANCEiDATE
which emit hanrdoua air contaminants as dell oed by the Bay Area AirLI�kl�lf"il
lity Management District? BOILER-COMP DHPOR 100,000 BTU)
Yev ❑❑No
a venadlhe"ala
rdousmItenab i ntsunderChapterG95of BOTLER-COMP(OVER 100,000BTU) jj ra �� 1'35J
the Califomk Health&Saf deWnat �
ctlon 505,75533and 75534.I �U7n !.a
un and that i(the bui gdave alenanl,that ltbmy NEW RESIDENTIAL MECH. SQFr
parol notify scaments which '�NC/T,�Mri��i/(�iB_QP�1(•I�RQ, , `'
scam ut dagent t ISSUED
TOTAL:
OFFICE COPY