19760 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ect Identification PERMITNO.
� gIdlsAddreea: 19760
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7 CITY OF CUPERTINOLBUILDING DIVISION
Centraaershrams: Lk.No: APPLICATION 1PERMIT
BUILDING-ELECTRICA4MUMBINGMWC NICAI, CATEGORY CONTROL M
' .' Architect/Engineer. Lk.No:
Q ELECTRICPERMFF FEE
BUILDINGPERMIT INFO
Address
IPflN4TI55UANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
[hereedionmlhatismlkmsedhe under BusiemannsoffeWms9de,and c- APPLIANCESRESIDENTIALingwitJOB DESCRIPTION
hoonseh Section to.and effeon3ofthe Bu.lneesand Pro(ef.ImsCode,and my s
license is In full force and effect PANELS n '
Licenseckes IC.If C VI as
Date Contractor UP TO 2DO AHM
ARCHITECT'S DECLARATION 201-I000 AMPS
Q ZO I understand my plain shall be used as public reads. OVER 1010 AMPS L1,001 AFM $/SQ.FT..
Way LicensedPm(eamul SIGNSELECTRICAL UTE R
6 -OWNER-BUILDER DECLARATION
o F Ihereby areasfOrmthat l am exempt from the Contractor's License Law for the S[eFLIAL CIRCUIT/hfISC �� IO
2 following on.(Section 7031.5,Business and Professions Code:Any city or TEMP.METER ORPOLE INST.
F� countywhich requires a permit reconstruct,alter,improve,demoWh,.rrepair 1
�§ 5� anystmMmpKortoib Wuame,alsorequbeatheappBanlfwauchpemdtto POWER DEVICES
Ole a signed statement that he is licensed pursuant to the provisions of the
3w Contractors Lianas LadPrf.er9(mmmenclnt wish xemptthe00)of Divi- SWIMMING POOL ELECTRIC LU`•/ kJ --
OJ Cordo.d.eLicensee aw(ChembruCede)orthat with Sempt7NXI)omand
< the bash for the alleged exemption. Any violation of Section 70315 by any OUTLETS-SWITCHES-FIXTURES
applicant(Ora permit subjmUtheappllcant to a civil penalty d not more than
Xm
undred dollars,($500). I NEW RESIDENTIALELECTR SQ.FT. STORIES TYPE CONSTRUCTION
�n I,as owner of the property,or my employees with wages as their sole
ensatiun,willd.thework and the structure is not intended or offered for
Osale(Sec 7096,Business and Pmfessions Code:The Contractors License law
$ docs nm apply to an owner of property who builds or improves there,,and OCC.GROUP RES.UNITS
who doessuch work himself orthrough his own employees,provided that such
Improvements am not intended oraHered forsale.If,however,thebullding oe TOTAL:
improvement hsoldwithinoneyear.fcompleli.n,thecwner-bu0derwLlhave
lFiLkurden of pmving that he did nd build or Improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE
I FLOOD ZONE APN
1 as ownerdr the property,am exclusively contracting with licensed PERMIT ISSUANCE
Th,Contra to columns the project(Sec.7044,Business and of pro ore Code:
The Contactors es the Lew does not apply tc ,f owner d property who
bu Rola or improve thereon,and who mntacis for such pio)em with a ALTER-DRAIN kVENT-WATER(EA)
cgp(lactw(seempt under
S tto the Cono-anorsLicense Law. FEE SUMMARY
IJ I am exempt urWsr Sec &P C r thio reason BACK FLAW PROTECT.DEVICE OUTSIDEFITS
•
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N er [e RECEIPT#
WORK MP di 1 NLAR ION FIXNRFS PER TRAP SCHOOL TAX Y N
QI hemby affirm that I have•artlOate of cme< to seB-loam,w a RECID'f
artRicateolWorkers'Comperaatlon Insurance ora certBkd Copy thereof(Sec. GAS F.A.SYSFEM.1 INCA OUTLET'S PARK FEE Y � N
3800,Lab C3 RECEIPT#
Policy# GAS EA.SYSTEM-OVER 9(EA)
Com y BUILDING DIVISION FEES
On
Copy h hereby furnished. GREASE/INDDSIRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified Copy Is filed with the city inspection division. ,
.CERTIFICATE OF EXhWP`FION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWF.I45ANITARY-S10RM EA 2(110,7 Date RCtSI t#
(Thissection need ns,be completed If the permit h(.lane hundred dollar
($10fiorless.) WATER HEATER W/VENT•/ELECTR ENERGYFEE Y_ N_
I artifythat In the performance of the work forwhich this permit Is based,
I shall nm employ any person In any manner n as to become subject to the WATER SYSTEM/TREATING
Workers'Compensationlam of California.Date PAID
O Z Appllant NEW RESIDENTIAL PLMB. SQ.FT. Date Repel t#
Z 0 NOTICE TO APPLICANT-.If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
(D
CMC,you=at forthwith Comply wlthsuch provisions orthis permit shall beBUILDING
LLL > deemed revoked.
FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
tl I hereby affirenthat there is a censuuction knding agency for the performELECTRIC FEE
7 Z anceo/thework(orwhkhthb b permit Issued(Sec.3097,C1v.C3 TOTAL
(> O ]ender.Name - PLUMBING FEE
LLI— Lendee.Addre.a QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W IcCdifythatl havereadthhappllationand statethattheabove in(omali.n
1 iscorrect.l agreeto comply with allctyand counlyordinancesand state laws PERMITISSUANCE FEE$ AI , �l
} (A relating to building construction,and hereby anthorlue representatives of this Z
Z city to enter upon the above-mentioned property for Inspection purpose. ALTERORADDTOMECH. Dat Recel t#
5 _ (We)agree to save,indemnify an d keep harmless the City of Cupertino P
5 agaimt hablllde,judgments,Costs and expense which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: _
against said City in consequence of the granting of this permit AIR HA LADLING UNIT(OVER 10,W0 CFM) CONSTRUCTION TAX
Signature of Applicant/Contactor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant Car future building oaupaot store or handle harardous HEATING UNIT(TO 100,ODO BTI) Date Retell t#
material as defined by the Cupertino Municipal Code,Chapter 9.IZ and the
I{ealth and SafetyCad cteon 25532(a)I HEATING UNIT(OVER 100,000 BTU) TOTAL:
qNoYe
rellltheappRead fu building occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hasardous air contaminants as defined by the Bay Area Air,
•
Quality Management lis No BOILER-COMP O}iI'OR IW,OW BTU) U�U�"�' J �I
4 Ye he a�WTNo
Yes
read salt r oety Code,Se requirements 5,2553 and
8.95 of LOILER-COMP(OVER IW,O()LN)
theif.,Health&gilding Cod.neni.ns25505,2e a tenant,
that ] a•s r.-
undentandthatifthc building duce oma ly have atenanL that lthmy NEW RESIDENTIAL MECH. SQ.FT.
responsibility to nosily the accv to requirement which the
Fri Las a.fa to f0 ancy.�
a
Owner or authorised agent
,at
ISSUEDBY:
10 TOTAL:
OFFICE COPY