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B.Bdog AddreV
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24127
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
BIIIIAING-ELECIMCALPLUMBING-MECHAMCAL
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CATEGORY CONTROL /
Co^IN.me: No:
as 5
55'/G Mn�A
A,claW fEaglncen Lk N.
.Q ICPERMI1Y rr }ELECTR
-BUILDING PERMIT -INFO
-BUILDING
Add-20r✓ led
❑ O
PERIZT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirmlhat Ism licensed under provWms o(Chapter9(rommene
Ing."I.tcttan7000)o(DlWaton3o(the BuslnermdPro(easlmsCode,rad my
licensebhfug dfM.
LlcenrC Lk.
Date Cnntndue a3 .'on�ff
ARCHITECT'S ECIARATION f
I understand my plans slug be used As public record a
Licensed Professional
APPL.IANCESRESIDEMTAL
I ]OB DESCRRR�YYFION
PANELS
201-IODOAMPS
FLOOR AREA
IN
S/SQ.FT.
OVER 1000 AMPS`
CAL �
SIGNSELECTRICAL
SPECIALCIRCUIT/MLSC I
OWNER -BUILDER DECLARATION
Q m utI aexempt from the Coors License Lsw for the
herebyaHirtimntract
_ (—�
�,J '� N C R E a a
TEMP MEppl ORPOLEINST.
POWER DEVICES C
following mature. 0e cm 70315, Busher and Professions Code: Any city or
mumywhichregWmape mmmhuKatter,Mpmve,demoWh,orrepair
anysuuctum prior to lb luuam., also requires the applicant for such permit to
file a algned statement that he b 1lmmed pursuant to the provisions of the
f
Js
SDWNC POOL ELECTRIC
OU'ILEISSV/ITCHESFIXIURES
Contactors License Law (Chapter9(mmmentlng with Section 7MM of DIW-
hat Code) orat he exempt therefrom and
Won of the Busher and Prdenbort
Use dab for the alleged exemption. Any Wolation of Section 70315 by any
appgan nt for, permit subjecuthe applicant los civil penalty of not morethan
VALUATION
pCd
fw.dmd dollars VISM.
Lj I, u owner of the property, or my employees with wages u their Acte
NEW RESIDENTIAL ELECTR _SQ.FT.
STORIES
TYPE CONSTRUCTION
compensation, will do the work. And the structure is not Intended or offered for
.Is (Be. 70K B olacom and Profmlons Code: The Contactors License Lw
don not apply to an owner of property who Wilds or Improves therms, and
whodoesmrhworkhimeetforthrough Msownemployees, proWded thatsuch
OCC. GROUP
RES. UNITS
Improvements are not Intended proffered fmsale. It however, the W Ildingor
TOTAL
improvement baold wlthinomyearofeompldioktheowner-bullderwN lave
tll9�urdenp( coin that he did wt Wild orlm row(m of sate.).
P e P wm�
-.
QrY. PERM _ 1BING:.PERMIT„' =- FEHr�,
,r'.:
FLOOD ZONE
ArN
L J L a owner of the Property, am exclusively ag aching with n Code:
.set mnswct the project (Sec 7016, and Profmlons Code:
ISSUANCE
PERMIT ISSUANCE
The Co to an o
The Contactors License Law don not apply e s f owner m property who
builds or Improves hursua and who mntnm for such p5ojsm with a
cgp71+ct...Anrlicensed punu etto the Contractors License Law.
LJ I am exempt under Sec. B k P C for this rcuon
ALTER -DRAW kVENT - WATER ffF:AI
_ !, i
r'sy
:L� ' `:"FEE.SIDE
BACK FLAW PROTECT. DEVICE
RES
DRAINS FLOOR ROOF, AREA, COND.
SANITARY RECE1PIe
OwnerDate
WORKMAN COMPENSATION DECLARATION
QI hereby Af(Irm that 1 have a certlficab of cmrnt to self -Inure, ors
certifleste of Workers' Compensation Insurance oacertl(kd copy thereof Dec.
;b C.7 G— a/
'T
pD(RRiES PER TRAP
SCHOOL TAX Y N
RECE P17 a
CAS EA. SYSTEM.1 INCA OUTLETS
PARK FEE Y_ N
RECEIPT
Pat.
C., 1;y!
CASEA.SYS1-OVER4(FA)
BUILDING DIVISION FEES
i copy is hereby furnished.
rti(led copy is filed with the city inspection dlvlaton.
CREASE/WDUSIRL WASTE INTERCEPTOR
PLANCHECKFEE
CREASETRAP
CERTIFICATE OF ECEMPFION FROM WORKERS
PAID
SEWE2SANTTARY-STORM E.A.200FI
COMPENSATION INSURANCE
(This Action need not M completed If the permit Is for cru hundred dollars
(SI 00)Is, I..)
Imftgl ththeperformanceofthewmkforwhichthiopemmbissued,
Date Recti tp
WATER HEATER W/VFM/ELECT(
ENERGYFEE Y_ N_
C
WATER SYSTEM/TREATING
I shall am employ any penes In any matter an as to become wbject to the
Woken Compensation Lsws of California. Date
PAID
NEW RESIDENTIAL PLMB. _SQFT.
Applicant
NOTICE TO APPLICANT: If, after cruising this CertBlcale of Esemphon, you
should became subject tithe Workers' Compensation provisions of the Labor
Date Re i til
TOTAL—
Code, you oust forthwith mmpty with such provision orthb pens t shall be
BUILDING FE
deemed revolmd.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
TOTAL
ELECTRIC FEE
Iherebyatftrm thattherebammmuctim lending agency forthe perform,
.am of the work for which this permit b Issued (See. 3097, Civ. C.)
Lender's Name
Lender'a Add..
orad dalethatiheabove d gate lam
I certify/hall loveread tMsappgcaty AM
bmrntobuilceto complywllh Wrdtyandcountyoerepreasatwes
PLUMBING FEE
-
q1Y: _. -?: ME CHANICACPERMTT; ., ' t , i. °FEE,_
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
of
or in reprexnpurposo(thb
relating to WTiding mnsove-ron,and hereby property
city W)aenter
eeupon to theabodemnify a. d propertyfor hapectit purpura.
(We) agree to uve, ensmNfy and keep which the City y Cupertino
agaWt WbWties, judgments, cases and expenses which may In any wa atwe
ALTER OR ADD TO MECH.
Date Reeei tic
AIR HANDLING UNIT (TO 10,(100 CFM)
SUBTOTAL:
against said Citya lthe gansh this permit.
f/�
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
Signature.( ppucant/ n or Date
FRHAUSTHOOD (W/DUCT)
CONSTRUCTION TAX PAID:
NA2AR USMATERI LS DISCLOSURE
Will the applicant orfuture Wilding occupant store or handle haaardous
HEATING UNIT (TO 100,000 BTU)
Date Recei HI
material as defined by the Cupertino Municipal Code, Chapter 9.iZ and she
Health and Safety Code eSSection 75532(a))
yes
No
I he Applicant carfutureWilding occupard use equipment or devices
HEATING UNIT (OVER 100,003 BTU)
TOT
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
which emit hacardous air contaminants as defined by the Bay Area Al,
Quality Management District?
IM YmNo
Thaw mad the hara[ous materials requirements under Chapter 5.95 of
the California Health k SafetyCod.,SMlons 755M, 25533 And 25531. 1
understand that lithe Wilding data not currently have alenan6twtltbmy
.fbfilytoramifythe.p.ntmthe.qubem.t.which.,tbemet
_
c )
SEP 1 '/
BOILER -COMP OHP OR 100,00D BTI
BORER-COMP(OVER 100,000 BTU)
N'EW RISIDENDAL ATECFT SQ}T
prior to issuance of a Certificate o(Ocupascy.
^Ir v
Acer �rk1l
ISSUED BY:
Owner or authodred agent Date
TOTAL:
OFFICE COPY