19787 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Buildln Pro en Identification PLRMIT NO.
•'- Building Address: 19787
9 L/ � qct 3 24
nen ante: Phone: A
To eSa oLCITY OF CUPERTINO-BUILDINGDIVISION : 2/2-�fqp
Contndor'.N.me: le. o: APPLICATION / PERMIT
• !72 BUILDINGELECTRICA PLUMBINC-MECHANICAL CATEGORY CONTROL
Archited/Engine. Lk.No:
QTY ELECTRIC PER FEE BUI DING PERMIT INFO
Address: p Stqr '
Llcene
LICENSED CON
ICENSEDCONTRSDEON
POWT
ISSUANE1:1�v1:1�
❑
IMylrmthat lam Bcrosed!under povlou..f aper9(mmc AIILIANCESRESIDENTUL JOB DESCRIPTION
ingwhSioll0W)ofDlvlNeBueivandProfeaonaCodend my
licenseeI.Infull 10 daffect,
iourador� PANELS
DateZ CUP TO 200 AMPS
CaARCHITECTS ECIARATION r
OVER00 AMPS
Off+0 Q I understand my plan shat be used m public records. OVER 1000 AM75 SQ.FT.FLOOR i $/�.Ff.
E j Licensed Professional SIGNSELECTRICAL L E D
«<< ILgL OWNEReBUILDER DECLARATION SPFLULCIRCUIT/MISE
O R � owing1heremum. t &km 7 31.5,Bxempa leo Business
and Professions
Lkeve LawAny for the
following reason.(Section 7031.5,Business and Pro(emiona Code:Any city or
K s"� countywhich rcpermitumaa permit tocovtruct,alter,improve,demolish,ormpalr TEMP.METER OR POLE INST. J�
S
..t anyslm mprlortolbhotamc alsorequlrestheapphunlforsuchper tto POWER DEVICES /
P 01e a signed datement That he V licensed pursuant to the proWiov of the
Contractor's License lndPromadomwnurcndag with xSection 70refof and SWIMMING POOL ELECTRIC VALUATION
elon3oflhe Bualneasend ProfemlevCode)arthathele exempt therefrom and
Q the barb for the alleged exemption. My violation of Section 7011.5 by any OUTLETS -FIXTURES J ,,,,VALUATION
applicant(ora perrdt subjects the applicant Hoa dvil penaltyd not morethan
five hundred dollars($500).
I,as owner of the ro NEW RESIDENTIAL ELECTRSQ.FT. STORIES TYPE CONSTRUCTION
,4 ❑ p perry,or he employes with wages r!herr sole
e a compensation,Business andwill do the kandlheatrude:Ture e Contraot ndM or offendw
for
O ole(Sec.7ply to Businessandof propeProdessionrty
Cade:ilds or improves
Wcevelew
j?j�$ donnossuchtorkhimself or mvnardproughhisonemporers,provided
thatand OCC.GROUP RES.UNITS
pp,, wprovemntsworktintenedorofghNeowne.If,hoeever,thebuiletauch -
improvementiarenotintendedearofco pl uk.ILh ter-gtOderwdingoe TOTAL:
Improvement bedd wilhinovyearo(compldlon,Iheowner-buBderwW Fuve
tFie„purden of proving that he didnd build orlmprove fm purposeofule.). QTy. PLUMBING PERMIT FEE FLOOD TAME APN
L_J L as owner of the property,am exclusively contracting with licensed PERMITISSUANCE
contractors to construe the pmjed(Sec.7064,Business and Professions Code; ..
The Contndor's Licenae Law dm cot apply to an owner of property who ALTER-DRAIN&VENT WATER(FA)
bullcia or Impames thereon,and who contracts ch for suIntojed - -
a with• FEE SUMMARY
agu(Tadm(d licensed nt
pursuant to the Coredofse s LicenLaw. BACK FLOW PROTECT.DEVICE
1_J I am exempt under Sec B&P C for this meson
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
• Owner Date RECEBPf N
WORKMAN COMPENSATION DECLARATION Fp(T RE&PER TRAP SCHOOLTAX Y N
❑I hereby affirm that 1 have• Insurance
of convent to copy thereof
or RECEIPT N
certifilabcate C.) orken'Compensation lvunnce macertifkd copythemof(Sec. GAS E.A.SYSTEM-1 INCA OUTLETS PARK PER V N
Policy
Tab CJ
Pdlry M RECEIPT M
GAS EA.SYSTEM-0VER 6(EA)
Com any BUILDING DIVISION FE
ES
Certified copy is hereby filed
the ed
city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE
Certified copy V(fled with the tlty inspection division.
CERTIFICATE OF EX EMPTION FROM WOR KERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA.200FT. Date Reeel tit
Uhhaedlon need not becomplded lithe permit V(carats hundred dollars
(5I00)mlen.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I tenor that too the person ncetithework so as to becomes
permit le Ito the
I shall nm employ en any person In any manner n v to become subject to the WATER SYSTEM/TREATING
' Worken'Compensatlon Tawe of California.Date PAID
icant
Z Q NOTI ETO APPLICANT:IL.fur making this Certificate of Exemption,you NEW RESIDENTIAL EMS. SQ.FT. Date Recei t#
should become subject m the Workere-Comperuatiun provLdmo of the Labor TOTAL:
N Code,ym mu at forthwith comply withsuch prowbimo.rthis permltshallbo
> deemed revoked. BU G 'EE .�Q
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a covtrudlon lending agency for the perform ELECTRIC FEE
D Z ante of the work for which this permit is Issued(Sec.3097,C1v.C.) TOTAL
U 2 4nderb Name 41w.4we-- PLUMBING FEE
LL I- Lender.Addreas QTY. MECHANICAL PERMIT FEE MECHANICALFEE
OW I.difylhatlhavereadthLsapphutionandpatelhattheabovemformation
IL Lscomed.l agreeto comply with a6 city and county ordinances and nate laws PERMITLSSUANCE FEES PAID:
} relating to building mvtrudlon,and hereby authorize representatives of this
N city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
? (We)agree to save,Indemrdfy an d keep harmlen the City of Cupertino Date Receiptit
V
against Babllitin,judgments,mets and expense.which may In any wayaomm AIR HANDLING UNIT(TO 10,000 CEM) SUBTOTAL'
IaR9 rut Bald Clry)n mnmqu��e gnnting of thle permit
\`{jl�� �/ca AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Snaturcof Applicant/Contndar Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
/ HAZARDOUS ATERIALS DISCLOSURE
Wllltheapplicant or future building occupant store or handle hazardous HEATING UMT(TO 100,000 BTI]) Date RCCej t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
Health and SafetyCade Section25532(a)I HEATING UNIT(OVER 100,000 BM TOTAL: )�
r-1 Yes KI No
Will ths.pplizart.70to.building mcvpantuee equipment or devices VENTILATION FAN(SINGLE RES(D) ISSUANCE DATE
which soil hazardous air contaminants as defined by the Bay Area At, - END t®,
. lity Managemont District? BOILER-COMP OHP 100,000 BTU) N
Y. No
shave m.dtheh..[YusmaterialarequimmentsunderChapter6.95of BOILER.COMP(OVER 100,000 BTU) ��p
the G71ve da Health&Sat Code,Sections 25505,25533 and 25534. I
understand that if the building does not mnently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requirements which must be met .a
rtolssua f nlficate of Occupancy. P ,1111P,"Ino
itir�,eai1 �, r2— .2 I"- 9� /
Omer or authorized agent Date ISS
/ TOTAL;
OFFICE COPY