19772 `APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm+cdldemllcalIm PERMIT NO.
Building Address: �I n
it/ GaL.a Y I J
772
Drs arae: hone: A
I-M- i�, P$� tics CITY OF CUPERTINO-BUILDING DIVISION .. n7�
Q
Contncmr.Name: U ,�
c.N. APPLICATION / PERMIT ,?^ 7
L 7 A s SS-0-7 I S BAILDING-¢ECTRICAt,'LUMBINGbfECtiANICAL CATEGORY CONTROL M
A:itect/Engineer. Lk.No:
n.
�T; QTY ELECTRIC PERMiT FEE BUILDING PERMIT INFO
Addre jezy 77N4-USA !-"j SAaPA C( PERMITISSUANCE .4M fE� ��y
LICENSED CONTRACTOR'S DECLARATION �l� l
I hereby efflrm that l am licensed under provisions of Chapter9(commenc APPUANCESRESIDENTIAL ]OB DESCRIPTION
ingwith Sedion7000)Of Dlvision3ofthe Buelnessand PmfngmsCodn,and my
I. Is In full f and eflM. �s PANELS
Licetuc Cbss Lk.N__ :J 07/ I S'
Date Contractor UPTQ200AMPS
ARCHITECTShallbeused
as public
201-1000 AM15
OVERIOOOAMPS SQ FT FLOOR AREA S/SQFT
totou 20 I uMentand rr0'plero shall be used as public mcouda
Licensed Professimusl SIGNS ELECTRICAL
< OWNER-BUILDER DECLARATION I SPECIALCIRCUIT/MLSC IGa
z I herebyaffirmthet lame.empt fromtheC rdee .e.Lkeve Law fnthe
following reason.(Section 70315,Business and Professions Code:Any city or
02 q TEMP.METOL OR POLE INST.
countywhlchrequbesaperr ttommtmc"ter,impmve,demlbh,orrepair
1006 anysbvcture pdorto Its issuance also requimtheapplicantfor such permit to POWER DEVICES
' file a signed statement that he is licensed pursuant to the provisions of the
FF C.M.cmr'sLtcerae Law(Cha Pier 9(commencing with Section 7000)of Divi- SWIMMING R70L ELECTRICF,30J sam3 ofthe Business and Pmlo
fesa ®Code)orlhat he b exempttherefmVALUATIONmand
E5�n,,,777777 the basis for the alleged exemption. Any violation of Section 7MIS by any OUTLETSSWITCHIRSFIXTW ES ..
<� applicant fora permit subjects the applicant to a civil penalty of not more than
five hundred dollars(55M. NEW RESIDENTIAL RLECTR I TYPECONSTRUCTION
I,as owner of the property,or my employees with wages as their sole
mmpensaflon,wBldothe work,and thestructure is not Intended or offered for
Oato(See.70K Prvfenbru Code:The Contradoe.License Law - I
S does not apply to an owner of property who builds or improves thereon,and Fa 01OC.. up RES.UNITS
G whodon w
suchworkhlmselforthrgh hlsownemployces,provided that such
Improvements am not intended proffered forsak.It however,theleuilding or TOTAL:
Improvement b sold within one yearofcomplelbn,the owner-builderwill have
,he of proving that he did not build or Improve for purpose ofuk.). QTY, PLUMBING PE INSFEUM )EP
u L as owner of the property,am exclusively contracting with licensed ApN
contractors to construct the pmject(Sec.70/4,Bustruss and Professloru Code: PERMIT ISSUANCE fa1N f�4, 11}p1 3113131
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN VEM-WATER(FN YI11, yl. DCr LIs.YM
builds or Improves thereon,and who contra for such plojeci.with a2-00 FEE SUMMARY
egWeetoHa)licensed pursuant to the Contadoe.Llcenee Law. BACK FLOW PROTECT.U I am exempt under Sm B&P C for this reason
Owner Date DRAINS-FLOOR W CONTI. SANITARY Y_ N_
RECEIPT 0
WORKMAN COMPENSATION DECLARATION a77X.[VRES PER TRAP SCHOOL TAX Y_ N_
hereby affirm cer
that I have a tificete of consent to veil-Insure,ora ITEC NN
ceoteafWorken'Compensation Insurance or a mrtified copy thereof(Sec.
380O,Lab C.) GAS SYSTEM-1W Ef PARKFEE Y N
Policy N RECEIPT N
Com ny GAS EA.SYSfFM-0 BUILDING DIVISIONFEES
Cenllled copybhereby(umished. - GREASE/IIWUSTRL WASTEI — NCIiECK FEE
MCeniffed copy b filed with the city inspection division. p
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP B / P7AID,99U
COMPENSATION INSURANCE SEWER-SANITARY-510RM F.A.200F1'. Date RCOCI t#
(1'hlsaedion need not be completed lithe permit b forone hundred dollars �A�,
(SICO)or len.) WATQ{HEATERWNENT/¢FLTR I I n' tsQER&UEE Y N
I cemifythat In the performance of thework forwhich this permit I.issued,
I shall net employ any person In any manner sou become ab'et to the WATER SYSTEM/TREATING
Worker:Compensst nLa IGu(p„ip Date ��.27 - A PAID
ZZ Appllant /e1 NhY✓RESIDPMIAL PLM9. SQFf. Date Remi t#
O NOTICETO APPLICANT:ILa er making led.CMBlcate of Fxemptt.n,y.
should become subjectto the Workere'Cempematioo provisions of the Labor TOTAL:
F W Code,yau must forthwith comply with such provisloroorthis permit shallbe O
> deemed revokedBUILDING FEE
. e O
CONSTRUCTION LENDING AGENCY SEISMIC FEE 71
0- z IherebyalRrmthat there b a construction lending agency for the perform TOTAL: 0 ELECTRICFEE 0
7 Z ance ofthe workforwhlchthb Fermat b Issued(Sec.3097,Clv.C.) / au�
V O Lender's Name PLUMBING FEE . O�
F Lenders Add. QTY. MECHANICAL PERMIT FEE
OO I cenlfythat l haveread this application and stafethattheabow information MECHANICAL FEE sOV
6 bcomed.l agree tocomply with all city and county ordinances and Asia laws JPERM17ISSUANCE 1„e OQ FEES_ PEiID:_
r W relating to bullding construction,and hereby authorize representatives ofthis Anuzcr
cit to enterupon the above-neenfioned fee W Ion a ALTERORADDTOMECH.
~ ? y(We)ato save,IndemN/y and keep Mese theInspection
of Cupertino Date seal t# '
V against liabilities,judgments,"sand expenses which may In anywayan-rue AIRHANDUNG UNIT(TO I0,000CFM) SUBTOTAL:
.g.h at cold Ci In caneequeme of the granting of this pemnit.
• � z_Z7� AIR HANDLING UNIT(OVER lO,ODOCFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date — EXHAUST HOOD(W/DUCT) sW CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wlllthe applicant or lutum building occupant store or handle hazardous HEATING UNIT(TO 100,OOD BTU) Date RCCCI I#
materbi as deli and by the Cupertino Municipal Code,Chapter 9.1Z and the
Health and Safety Cade Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) - TOTAL:
Yea No
Willlheapplicant or tum building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havrdous air contamivnts as dented by ted Bay Area Air n
ality Management District? BOILER-COMP OFT'OR 100,000 BTU)
Yea 10��-�No
have read the h=rdous materials requirements under Chapter 6.95 of BOILER-COMP(OVERIM,000 BTU)
the California Health&Safety Code,Sedimn 25%5,25533 and 25536.1
understand that lithe building don not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT
responsibility to notify the occupant of the requirements which must be met
prior to issuance of a Certificate of Ocmpa my.
Owner or authorized agent Date ISSIIEI
' TOTAL: 21,00
OFFICE COPY