20848 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USEBALL POINT PEN ONLY
Rulldin Pro M 1deml0oaio^ PERMIT NO.
I 5� 20848
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CH10—r-6 Huewq CITY OF CUPERTINO-BUILDING DIVISION c
Cmtraators Name: Ile No: APPLICATION /PERMIT & — 3 —(TIO
IO
Am BIRLDINGELECMCA MLTMBINGEG
MCLHANICAL CATEGORY CONT&
1.Ic,No: (�
Archxeci/Engfrccr: ,ems
Qry ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrn.: )qqb-389 PFRMITISSUANCE LI—C;V reTi
LICENSED CO.NTRACTOR'S DECLARATION LJ�
I hereby aHbm that l am licensed under provisions of Chapter9(mmmeec APPLIANCES-RESIDENTIAL BD6C)RU N
Ingwlth Seet1onM)())of DWislon3ofthe Buynessand Prerfesym.Code,and r
license b In full(ora and dfM. PANELS A 1 T'
Lben.e Cbz Lk.Y ,a{.N
Date Contractor 1 a\ ` ll
ARCHITECTS DECLARATION 1-1 AMTS
Pqqp��
00
I understand my plans stall be used As public records OVER 1000 AMPS SQ.FT.FLOOR $/9Q.Fr.
E t, Lkensed Professional SIGNSELECTRICAL �1L�
Q FA OWNER-BUILDER DECLARATION 5[eECIALCDICUEf/MESE �A ! ``
]µ ms Ihcmbyaf m thatlamexempt frornthe ContrxYori License law for the
qq�y folbwing naem.(Benson 70115,Bwlnea,"ProfesionsCode:Anycityor
coun
F ay`a3 tywhkhrequirnaper tomnstmn,altenlmprove,dennlbkorrepdr TFIHP.METROR1OLEWST,
aystmnum pdortoib Issuance.]..requlrestheappllant(ormch pemdt to POWER DEVICES leO
O I&•signed statement that ha Is III pursuant to the provbbd ns of the V � l
µ Contractor's Li law(Clapler9(mmmencingwtlh5Mbn70WDWI-
yon 3 tiabrt b exempt the BuslnessAnd PrefensCode)orthhe therefromaed SWAfMINGIOOL ELECTRIC A
P •--tt the heals for the alleged exemption. Any Wdatbn of Se acn 70115 by any lj�ff� As '
applicant for a permit subjects theapplicant to a civi penalty dnd more than OUITLETSSWTTCHEBFD(TURES a
E IlvLundrsd tidies(55001. NEWRESIDFMIALELBCIR SPI'. FIN WZD� M�14
CONSTRUCTION
I,as owner of the property,or ray employees with wages a their wk
compensabm,wW doth.wor14 and the.tracture b rent Intended or offered for
❑ sak&c7D1d,Bwiaa and Pmfrsloa Cudr.The Contradoes lJceae Law
$$ don est apply toan owner dproperty who builds orlmpmves thereon,and UNITS
EEE whodoessuch work himself¢through hlnownemployees,pmvlded that such
lmprovemeNsannotbtendedoroffemdf¢rak.T(,however,thebuldingor TOTAL ImprovementbwldwithinomyurofcompletloktheownerbuiderwtDhavet enol pmvingthat he did rust build orlmprove f¢purpose ofsale.). QTY. PLUMBING PERMIT FEE
er of the property,am exclusively contrMing with II¢nsed
tractor to our ymd the Pm}M(Sec 701{,Bwlness and Profevbns Code: � PERMIT ISSUANCE 1-2,00
Contractor',Lkcenue Law does not apply to an owner of prop,rty who ALTERDRAW k VENT-WATER(EA)Ilds wn re
or Imprthereon, and who contracts, for ad pTocts with• - (�
TP�+ctorW xcensed pu nuant to the Cmtnct°I•License law. FEE SUMMARY
f I am exempt under Sec B k ni
C for this ren BACK FLOW PROTECT.DEVICE
,
DRAINS-FIAOR ROOF,AREA,ODND. SANRABY Y N—
Ovner ECateL RECF9aE s
WORKMAN COMPENSATION sent
ESS PERTRAP ,lyt SC-IOOLTAX Y N—
QI hereby,(firm thatI haus certificate off cacxnt to"ll-insure,or• LV
cenido(Worken'Compensabm Nunn¢m•certified mpythermf bee. RECEIPT— NNY
Lab
38(q,lab G) GAS EA.SY51T],1-1 WC40U-II.EIS PARK FEE Y_ —
Pdky Y RECEIPT Y
GAS P.I.SYSTEM-0VFR!(PA)
CnY BUILDING DIVISION FEES
�CertNed copy Is hemby furnialmd. GRPSSE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
�CertNed espy b(fled!d wIth with the city Inspection division.
1�-73
CERTIFICATE OF EJ(Q.IPTION FROM WORKERS GREASEIRAP PAID_'[� r7>,7 [
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA,pff E Date Recei t#
(fhb mess.) need n¢bec°mpined Btk permit b(a one hundred dollars
(sleo yth WATER HEATER W/VEl /ELECTR ENERGY FEE Y N
Tec not nip TIT the p pe,.I.
eW¢k for t.bco pertnxct to
—
1 shall rad employ any pea s in any manner ao a to bemrro subject to the WATER SYSTEM/TREATING �0
W plicanC°mpewtbn TawsdGWomb.Date PAID
O Z Applicant NEW RESIDINfIAL PLMB. �.ET. Date Recd t#
Z z NOTICETO APPLICANT:If,after mlang thisCertBlcete of Exemptbn,you
should become aubjM to the W°rken'Compematbn provisionsof the labor TOTAL:
F N Code,yen must fcethwxh comply with such provbbns°rthb permit alWl be UI Z/0.�
LU � deemed revoked.
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Ihereby affi hatthenba mratmnlm Lending agency for the perfomF TOTAL: ELECTRIC FEE Lq7
7 Z once of the Worklor which thb pemdtbbmed bee 3097,CN.C.I
1..1 O lender.Name PLUMBING FEE a
IL H Larder.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O1rti. hagarst lehave this apapdtlyloanamunsuattyetohrdtlnhae nambv,enInformation
W
eUtelawa PERMIT ISSUANCE �Q7 FEES PAID:
} N misting to building eorutructim,and hereby authorize repmsenlatiw o(thls
Z my to...upon the above-mentbead Property for iapeabn purposes. ALTERORADDTOMDC a DatC ReCCI t#
(We),gree to saes,indemnify an d keep harrrd .the City d Cupertino
V against O,biByes,judgments,mets."e.peae,which may ins°yway..e AIR HANDLING UNIT 0010,000 CFM) SUBTOTAL:
ag.iatrai Byi^ e f the granting d led,permit.
NRIiANDUNG UNIT(OVER IO,ODDCFO CONSTRUCTIONTAX
8 Applicant/C n ctor Date EXHAUS17 HOOD(W/DUC) CONSTRUCTION TAX PAID:
HAZA OUS MATERIALS DISC URE
WIIl the appBantm tum bulldingomapantato rha"khawdvw I-IFA7lNC UNIT CTO tN,000 BTU) Date Recei t#
naledalasdefined by the CupertinoMu Ncipal Code hapter 9.17,and the
Health and Safety Cade SMIon 2553](.)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
Yes �]No
WWtheappiant or future building a pant use ryulpment¢devkes VENTILATION FAN 6INCLE RESID) ISSUANCE DATE
which emit ha andnu,air contaminant..,deflad by the Bay Am.Ab
Quality Manuumcrt District? a BOILER-COMP(310U)
4 Y', HN OR 10,000 BT ���
have read the havg °mat<rlab nqul¢menn underChapter 6.95 o/ BOaQt-COMP roves 100,000 BTI!)
the GlOomlu Heallh&S fety Code,Stta m2S505,25533and 25531. 1 RESIDENTIAL
urdenta"thati(thebu0dingdoanot ,ctlyhaveaten..ithat itis my NEW RDENAL MECH. SQ-Fr1 ILata
raponsbdityto edify the omnpant d the requirements whkh mut be met
prim to lsnurce of.Certlflate of Orcuparuy.
Ownerm auth°rived agent Dace ISSUEDB
" y
TOTAL:
OFFICE COPY