20640 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pea'ed Identification I PERMIT NO.
Building Add ren: �z I ck a)A a lW \-�z os RAQ�F'ro20640 O 6 A O
te ame� GGY\3mr one: G 4T
0CITY OF CUPERT[NO-BUILDING DIVISION
T"
7' Lie.No: APPLICATION / PERMIT
BU[LDING-E.FGTRICALML BING-MECHAMCAL CATT-GORY CONTR .Y
ArebRM/En neer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Ad
I'EtMITI55UANCE. ® ® ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby thSedOlrmthat fDiv Bcmsaftheunder BuprovisionsmfeW=srode,and AI'fef1ANCESRESIDENTIAL JOB DFSCR/I'1'ION
EcamehSection 7000)0 de elon3o(the BuslroasandProfesaionsCode,and
Ikenaa la In fu (o and cited. PANES
Llcene�LicYc
Corl+
Date Hrettor
ARCHITECTS ECLARATION XII-IOOOAMPS ' 7 '
µQ000 !u ypls IuB be upublic emrds. OVERIODOAM(P�S y SQ.Fr.HAOA�AREA 5/SQ.Ff,
E� Lice essioul SIGNS ELECTRW F P
f'Y r1 "IT I..tgZ
6666 6 OWNER•BNL R DECLARATION np�r
SPECIALCI(CIRT/MISC al/n
Zs, Ihercby affirmtOWNER-xempttro DECLARATION
License Law for the
following reon.(Section 7(315,Budiusa and Pref sedeCode:My city or
O asr. TEMP.MEIT72OR POLE INST.
pEl counlywhkhdum rcquiresa pemnutlescanrocoutatutedtr,bnprovam forsch,orto
anyatacture priortoitsthat he Is licensed
Fru than t the provisions
ofpermit e POWER DEVICES
file a 4gned statement that M b Ikensad pursuant to the proWions a( the
Ole Conlractore Lkemue
rLaw(Ctapler9(mmrrcnWgwlthSettion7000)o(Dlvi-
SWIMING IDOL ELECTRIC
ns
VALUATION
Q S the basis for the alleged exemption. Any violation of Section 7031.5 by any M more OUTLETSSWITCHESFIXTURES 3a5 ,f y\ 9. ��.
111���444ilJilJilJ apphunt for a permit subjects the applicant to a civil penalty net than V
$ five hundred down($W. NEW RESIDENTIAL ELECTR
1,as owner of the property,ar my employees with wages as their sols, �'�' SPORTS TYPECONSIRUCTION
cope asation,wHl do the work and the drum.lancet Intended or offered for
Osa1e(See.7046,Buslnem and Pro(enions Code:The Conrado/a License law ?,1
$ does rot apply to an owner of property who builds or Improve,thereon,and 1 Y-a V OCC.GROUP RFS.UNITS
who doessucbworkbiceselfothrough hisown employeesprovided that such
Improvements arc not intended or offered for sale.It,however,the building or TOTAL: a
Improvement issold within omyearof completion,the owner-builderwill have
t1A,Zurden of pmving that he did not build or Improve for purposes of sale.). QTy, PLUMBING PERMIT FEE
LJ L as owner of the property,am exclusively ecntrading with licensed FLOOD ZONE APN
commetm to muwct the pro(ect(Sec 7046,Business ami Profsnlou Code: PERMIT ISSUANCE
The Commences License law does not apply to an owner of property who
builds or improves thereory and who comram for such ptojects with a ALTER-DRAIN&VFNT-WATER(EA)
agR(��dor(s)licensed pursuant to the Contractor's Llcenss Law. FEE SUMMARY
L.J I am exempt under&c. B&P C for this reasonBACK FLOW PROTECT.DEVI
Owner Date RROO$AREA� ND. SANITARY Y_ N—
Owner Y
WORKMAN COMPENSATION DECLARATION PRR TRAIs) 1 O SCI{(ALTA% Y N
�I hereby affirm that I have a certl0este of consent to self-Inmre,or a RECEIPT N
cerd(Icamod Worken'Comperuatlon Insurance oracerllfed copy thereof Esc. AS pA.SYST'EM-I G PARKFEE Y N
3800,fab C.)
Palle,Y RECEIPT Y
c,(�/6a1.� _
Com any fur BUILDING DIVISION FEES
Certified copyb heciwturnlahed. GREASE/WDUSIRL WASTE INTERCEPTOR PLANC14ECK FEE
Certified copy ls(fled with the tlty,W pedlars division.
CERTIFICATE OP EXEMPTION FROM WORKERS' CREASE TRAP PAID �, —'
5653
COMPENSATION INSURANCE SEWERSANITARY-STORM EA.200FE. Date Remi tN V1\��
((hlssection need not be completed If the permit bfo ane hundred dollars
(B10G)orlen.) wATTx{TATER w/vENTIELECTR ENERGY FEE Y N
I wrtl(y,that N the performance of the wok for which this permit is issued,
I shall not employ any person In any manner so as to became subject to the WATER SYS717d/TREATING ^
Workers'Compensation laws of California.Date PAID
z Z Applicant !J'!`'']ApplicantNEW RESIDENTIAL PLMB. SQ.FT. Date Reml tt1 s
co
Z Q NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you -
shabld became subject to the Worken'Compensation provisions of the Labor TOTAL: .110
U) Cade,you rust forthwith comply with such provisions or this permit shall be BUILDING
EE jCft$,Cj0
W > deemed revoked. •
CONSTRis atom LENDING AGENCY �ZsOO SEISMIC FEE0. 6
M Z Ihd thewtirmthrttberebacanstattion lending agency 097,Ci(orthe perform TOTAL: ELECTRIC FEE Cy
� Z named the worklorwhkhthls permit lslseued(sec.3097,Civ.C.) a s
V O Lender's Name PLUMBING FEE a
)— Lenders Addresr QTY. MECHANICAL PERMIT FEE
LL MECHANICAL FEE
O W Immo.It Sre erne lywith allcity
and co my ortth,above ld date(laws
a bcoingtobgreemcommuctiohandtyandmuhoardinanmandresioIssue PERh1RIS5l1ANCE F �yvo 2�a
Lto relating to building constroctlory and Mreby autborlu rcpresenmtivn of this
F Z tlty to enter upon the above-mentlomd property for Inspection purposes. ALTER OR ADDTO MECH. Date ReCei t>t44
_ (We)agree to save,indemnify an d keep barmlen the City of Cupertino
agabut llablBtlea,judgments,cortsani expenses which may In anyway acme AIR HANDLING UNIT(T010,000 CFM) SUBTOTAL:
ago Wt aaM City in consequence,of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Sighalure of Applicart/Contractor Data EXHAUST HOOD(W/DI1C'D
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the
as ,fined by or
ertino Municipal
adle, hapten 9.hanrdous HEATING UNIT CED l00,OW B71)) Date Recei Ip
material as defined Coal
the Cupertino Municipal Cade,Chapter 9.12,and the
HeallhaM Safety Code Ion 75532(a)7 HEATING UNIT(OVER 100,010 BTU) TOTAL:
RillthY
es o
e or Nre applicant building occupant use equipment or devices VFNIILATION FAN(SINGLE RESIDE ISSUANCE DATE
hich emit luurdous air contaminants as defined by the Bay Area AJ,
it Maugement Diat et? BOILER-COMP OFIPOR 100,000 BTU)
Yes No
ve read the hoz ase materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health&Safety Code,Section 25505,25533 and 25536.1
cruised ndthatifthebuildingdoesndmP tenant,that It is my NEW REEDENHAL MECH. SQ7•l'.
responsibility to natlfythe mpant of thewhich rust be met
prioeol
ace leofOmup
Owner or authorised agent Dale TOTAL: ISSUED B)'
OFFICE COPY