20085 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address;
ioe oo AAOX-re�lyyy,���e"� �s���Xr vp• cu z�,t C41 20085
tV4060 CV4Wfit4!M — WC, 4ffi CITY OF CUPERTINO-BUILDING DIVISION
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&/&M~ APPLICATION /PERMIT CATEGORY
`o LIc.NoILDINGELECTRICALPLUMBINGMECHANICAL
a{ QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
PERMITISSUANCE VO
..® ❑ 1:1 ❑
LICENSED CONTRACTOR'S DECLARATION
I herebyteffirret that l am licensed under provisions of Chapter9(mmmere APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Jim..1.1.full farm andtefect. hegugnessand Prof.WonsCode,and my PANELS �••t�.w�. � .6i
Llmnse Class Lie.0
Date Contract. UP TO 2DGAMPS
ARCHITECTS DECLARATION 701-1000 AMPS
09z0I understand my plana shall be used u public records. OVERIODOAMPS SQ.FT.FLOOR AREA $/SQ.Ff.
Licensed Professional SIGNSELFGTRICAL
6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
Z owing y mason.
(hat l am 31.5,Bottom
and
sio sCode:law for the Z�0 CO Q
following rescan. iBeetle permit
to Bugness and Professions Code:Any do,or it
O�I.� TEMP.METfIItOR POLE MST.
�� county which rcqulresapereNt to construct,often Improve,demaWh,arrepalr
Q any arm=re prior to its issuance,also requires the applicant for such permit to POWER DEVICES
[S file a signed statement that 1e to licensed pursuant to the provulona of the
Contractor.License Law(Chapter 9(commeneing with Section 7000)of Owl- SWIMMING POOL ELECTRIC VALUATI
.1on3o4the Bm
usessand Pro(emlmu CWe)orthat he is exempt therefromand ON
O Q.••777 the basis for the alleged exemption. Any violation of Section 7m LS by any OUTLETSSWITCHESFIXTURES
�n3u applicant/ora permit wbjeRa the applicant to a civil penalty of not more than
five hundred delta.=0). NEW RESIDENTIAL ELECTR
F1I,as owner of the property,or my employers with wages as their win SQ'Fr' STORIES TYPE CONSTRICTION
compensation,will do the work and the structure Is not intended or offered for �J
❑ as le(Sec 7044,Bugrm.and Prufessl.m Code:The Contractors License Law 4-
S$
does not apply to an owner of property who builds or improves thermn,and OCC;GROUP RFS UNITS
who does such work himself orthrough his own employers,provided that such
Improvements are not intended or offered for sale.If,however,the building or TOTAL:
Improvement issold with in one yearofcomple cen,the owner-bullderwlll have
tlALkrrden of proving that he did rout build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE
FLOOD APN
LJ
4 as owner of the property,am exclusively 04,Business
ess and
with licensed pFRh11T ISSUANCE
Th Cotrractrom tocoriLwcttheproject(Sec apply
to
and of pra.na Code:
The Contractors Licms then Law dues not apply et t f owner of ei cta W who
W IWa or Improves thereon and who mntracb for such plojede wltM1 a ALTER-DRAIN&VENT-WATER ff.NN
cg1Lt currWlicensed pursuant to the Coretraciorsee s LicenLaw. FEE SUMMARY
LJ I am exempt under Sec. R k P C for this reawn BACKFLOW PROTECT,DEVICE
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
Owner Date RE)=EB?Y
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL 7A% Y N
I hereby affirm that ceflca
I have a rtlte of concent to self-insure,ora RECEIPT 9
ce te.furorknYComper tloal.summoraa"ifledmpythemof(Sec. GAS EA.SYSTEM-1 INCAOU1LETS PARK FEE Y N
MOO,Lab C.) RFLEIf NM
Poilry N GAS EA.SYFrEM-OVER 4(FA)
Com any BUILDING DIVISION IT CS
Ca
copy is hereby fumlahed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
.I� erAlfied copy ta,llled with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCESEWER-SANITARY-STORM PA 200F1'. Date Remi tp
(Thlesectlon need net be completed If the permit Is forone hundred dollar
($iW)mIxsx) WATER HEATER w/VEM'/ELECTR ENERGYFEE Y N
I oertilythat lathe perfo rromm of the work forwhich this permit Ia.wed,
1 shall not employ any person In any manner w as to became wb)cd to the - WATER SYSTEM/TREATING
Workers'Compensation Laws of CalifomO.Date PAID
O Z Applicant NEWRFMDEN7EALPLMB. SQ.FL Date Recei tN
Z Q NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you p�
fshould become subject to the Workers'Compereedion provlsiom of the Labor TOTAL: oa•
N Cede,y.0 must forthwith comply wuhsuch preAsionamthls permit shallbe BUILDING63 .,rD
W 7 deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE (T.of
C Ihembyaffirm that there is a corestrucilon tending agency forthe perform, ELECTRIC FEE
3 Z ance ofthe work for which this permit It Issued(&c.3097,CIv.C.) TOTAL:
V O Lender's No PLUMBING FEE
LL f lender§Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O WImnilythatlhavemadthbappUmtionand etatethatthe above Information
1 Is correct.I agree to comply with all city and county ordinances and gate laws PERMITISSUANCE FEES PAID:
>. W relating to building construction,and hereby authorize representatives ofthls
cit to entero n the above-mentioned property forW lion ALTERORADDTOMECH.
Z y w P perty �` p"rpuper Date Receipt#
(We)agree to save,Indemnl d keep harmiess the City of Cupertino
V against liabilities,jud9 gee ezpea.:rt h may manywayacaue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
d City in eams of a granting d this permit.
J�J �jy,� AIR HANDLING UFITf(OVER IO,000CFM) CONSTRUCTION TAX
tore.!Appucant/ ommetor Date/'%/J— EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theapielimnt or future building occupa^tsmre or handle havardous HEATING UNIT(TO I0%0D0 BTU) Date Recei Ip
-material as defined by the Cupertino Municipal Code,Chapter 91Z and the
I Ic.Ith and Safety Cod Section 25531(a)T HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes N No L�
Willthe applicant or tum building occupant useequipnrnt or devices VENTILATION FAN(SINGLE REBID) ISSF}A�tl�EDATE
which emit havardous air contamlna^ts as defined by the Bay Area Air W_
Quality Management District? BOEER-COMP OHPOR 100,000 BTU)
Yn I/U No
I
love read the h ue materials requirements underCM1apter6.95 of MER-COMP(OVER 1013,000 BTU)
the California I-lealth k Safety Code,&dlmm 75505,75533 and 75536.1
understand that if the building don not currently have a tenant,that It is my NEW RESIDENTIAL MEGA. SQ.Fr
res ruibilitytIfty the occupant of the requirements which most be mel city of rllpQrtlno .
p' r Lssuancc ora ' rt i e f cm anry. / -s�D
(Qwner or authenord agent Datc TOTAL: ISSUED BY; Q
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OFFICE COPY