20789 APPLICANT TO1L�LIN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - - PERMITNO.
BuiidmBAddress: n O (�(�
1,1114 094– �s9 - Y9Sa G
sate: ane: _
.nerrt89_ CITY OF CUPERTINO-BUILDING DIVISION 7 23I5o
aaor' sate:
antLk.Na APPLICATION I PERMIT
06 Z I BUILDINGELECTRICAI.PLUMBINGMWHANICAL CATEGORY CONRtOL0
roMt /Fnglneer. Lk.Na
QTY ELECTRICPERMIT FEE BUIL GPERMITINFO
Address 06 r PFRMITISSUANCE ❑ ❑ ❑
LICENS ED CONTRACTOR'S DECLA ION
I hereby a04m that sat licensed under provisions of Chapter9(comonenc- APPLIANCES-RESIDENTIAL DE KIPIION
tngwlth Seaton7OW)of DiAsion3ofthe BaNassandPmfewmsCode,and my
licenu la In (o d d(ea. Q PANELS ! N
Date in r z� ,
Date Contractor e�
ARCHITECT'S DECLARATION 701'1000 A0MAHPSM
QO I understand my plans shall be used as public records. OVERIODOAMPS SQ.FT.FLOOR ARLA S/SQ.FT.
Way Licensed Professional SIGNSELECTRICAL
�6 OWNER-BUILDER DECLARATION $PECL1LCItCUCI/MISC
7 � Ihembyafarmthatlamexemptfromlhe Cant..) is Li.nwUwforthe
pp following reason.(Section 70315,Business and Pmfesslons Code:My city or
O Z`• TEMP.MEIFR OR POLE INSf.
K� countywhlch mrylmapermittomatmct,alter, demoWF,orrepair
S anystmctum prior to its issuance,also requlmtheappllont farsuch permit to POWER DEVICES
.. file a signed statement that he It Ilmosed pursuant to the provisions of the
Contractor'sLicense Law(Chapter 9(mrrurencieg with Section 7000)of Dlvl- SWIMMING POOL FlECTRIC
llA
slon3ofthe Bu.lnessand Professba Code)orthVALTION
at heisexempttherefromand
Q 5 the basis for the alleged exemption. Any violation of Section 70315 by any OUTLEISSWITCHFSFIXHJRES .(�
applicant fora permit subjects the applicant too civil penalty of not more than D
five hundred dollars($500). . NEW RESIDENIMAL ELFC FT.
❑1,as owner of the property,or my employees with wages as their sole SQ RI TYPE CONSTRUCTION
( compensation,will do the work and the stroctum to not Encoded or offered for
O sato(Sec.7066,Business and Profnaloa Code:The Contradota Ltd.Law
$ does rat apply to u owner of property who builds or Improves thereon,and OCC.GROIR' RFS.ITMTS
who does such work hirmiselforlhrough hlsown employees,provided that such
Impmvemenls are not Intended proffered for sato.If,however,the building or 6 AL:
Improvemrent issold within oneyearofcompietion,the owner-bullderwlll have
t}�urden of pmving that hedid notbuildorimproveforpurposeofaxie.). QTY. PLUMBING PERMIT -,E FLOOD ZONE APN
U 1,as owner of the property,am exclmnl
lvely coracBng wflh Licenced pp IT13'UANCE
cuntrach.to coatrua the project(Ser 70K Basham and Professloa Code:
The Contme or's License Law does nor apply to an owner of property who - ALTER DRAIN&VENTWATER(EA
Wilds or Improves thereon, and who contra for such ptu)em with s FEE SUMMARY
d;E4.ctm(s)Licensed pursuant to the Contmolm.License Law. BACK FLOW PROTECT.DEVICE
U I am exempt under Sec. B&P C for this rommaOUTSIDEFEES
Owner Date DRAINS FLOCK ROOF, SANITARY Y N—
RECEIPT x
WORKMAN COMPENSATION DECLARATION WXNItF_S PER TRAP SCHOOLTAX Y_ N—
QI hereby affirm that I have a ceni0ate of consent to self-Inure,or RECEIPT x
ttrtl0ate ofWorimm Compeuitlonlesumnce or a certified copy thereof(Sec. GAS EA.SYSTEM-1 IJC.60VILEfS PARKFEE Y N
3800,Lab C.) —
Poliryp r DINGR�EJDIVISION
Com any GAS EA.SYSTEM-0VER4(PA) BUILDING DI VISION FEES
�Ce.yl d res V hereby(umlehed. CREASE/INDUSTRL WASTE INTERCEP PLANCHECK FEE
�CenBiedco y b Bled with the city lnspectiondl llon.
CERTIFICATE OF MEMPr10N FROM WORKERS' GRE-ASE7RAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA]OOFT Date Recei to
(This section need not be completed If the perndt is forone hundred dollars
(Sl 00)or less.) WATER HEATER W/VENT./FIcCTR ENERGYFEE Y_ N—
I mrtlfy that in the performance of the work forwMch this permit Is Issued,
I shall not employ any person In any manner so as to homm a subod to the WATCR SYSTEM/TREAUNG
Workei Compensation laws of California.Date PAID
—
0 Appeant Date Recel til
2It, akingemptio NEW RESIDENTIAL I'LMB. SQ.FT.
Z
NOTICE APPLICANT. aftthisCertifpro is Ens ofthe ,you
should become subject to the Worksn'Compensatlon provisions ofthe Labor TOTAL:
� N Code,you must forthwith comply with such provisions,orthb permit shall be BUILDING .00W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Iherebyafemnthat then 9 a matructlon lending agency for the perform- TOTAL: ELECTRICFEE
M Z an of the work for which this permit b Issued(See W97,CIv.C.)
02 Lender.Name - PLUMBING FEE
F Lender's Address QTY, MECHANICAL PERMIT FEE
O WlceAifythatlhovereddthisappllatbnandstatethattheabovelnformation MECHANICAL FEE
IL iscorrert.I agreeto comply with all cityand county ordinance and Asia laws PERMIT ISSUANCE FEES PAID:
). N relating to Wlldingmmatmctlon,and hereby authorlie mpresentativesofthl.
H city to enter upon the abovcmentloned property for Inspection purposes. ALTERORAODTOMECH.
2 (We)agree to save,Indemnify an d keep harmless the City of Cu pen loo Date Reeef tM
V against liabilities,judgments,comma and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:`
against mid City In consequence of the granting of this permit.
AIR HANDLING Ilb71T(DYER 10,000CFM) CONSTRUCTION TAX
Slgatureof Appllonl/Contractor Date EXHAUST HOOD(W/D[1C'U CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE -
Wilt the applicant orfulure buddingedupart store or handle hazardous HFATING UNIT(TO 100,000 BTU) Date ReCei t7J
material as cleated by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety Codi too 75532(a)7 HEATING UNIT(OVER 100,00)BT1A TOTAL:
Ye. �Q No
.Will the applica turc building occupant use equipment or devices VENTILATION PAN(SINGLE RFSID) ISS ATE
which emit hazardous air contaminants as deBred by the Bay Area Air
Quality Maam
geerd Mal BOILER-COMP OIE'OR 100,000 BTU) e
4 Ya No
have read the hamar "usmaledalsrequimt nbunder Chapter6.95of BOILER-COMP(OVER 100,000 BTU)
the C.Ifmnia Health&Safety Code,Sealoa 75505,75533 and 15536. 1 { .y
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQF7 City Of CIIDPI`TOO
mapomibllity to notify the occupant of the roqulrement,which most be met
pr oiesuance Cem to of Ocmpancy.
Ow or authmimd agent Date
Mau ISSUE �( t
TOTAL:
OFFICE COPY