19645 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pral,t IdentificatIon PERN[IT NO.
Buildin Address:
/y l �c �yJ
wnersName'
ame - Phone: A A A
Wil CITY OF CUPERTINO-BUILDING DIVISION ,111 .Z_ga
Contractor.Nam: _ d/Lk.No: APPLICATION / PERMIT -
BUILD.NGFLECTRICALML BINGMECHANICAL CATEGORY CONTROLx
Archited/ glueer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrca: -`/ PFRMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION I�f
Iherebyafflren that lam Bcesed under Firmest onaof Chapter 9(co)menc. APPLIANCESRESIDENITAL JOB UEscRrPTION-
Ngwlt Cf.. J0I of Dlle.I 3o(theButl---- sCode,andm T2e�4lrs To •CxIJTl1�
license is in faille an effect. PANELS
License Ciao ( C ant r
Date Conerador M
ARCHITECT'S DE LA ION 201-1000AMPS
0 CIO
H [understand my plans shall ere
be used publiccorde. OVER 1000 AMPS SQ.Ff.FLOOR ARG E/SQ.FT.
t�./t Licensed Professional SIGNSELECTRICAL
¢Bi OWNER-BUILDER DECGRATIONSPFLIALCB(CUIT/MLSC •, r ^ r n r 1! I
7L, � 1hereby.M.thR
at I am exempt from the Contraor's License law for the
Q following reason.(Section 7031.5,Business and Prefealone Code:Any City or )
K� to
county which requires a pemeltcomtruct,alter,Improve,de=lhh,orrepair TEMP.METERORPOLEINST.
g5 a anystructure priesto its iuuance,also requ.restheappBant for such permit to -
E yys V file a signed statement that he b licensed pursuant to the pmvbiora of the POWER DEVICES
Ou, Cort2l ofth'B.k .elaw(Chemio Cco e)orthathethumptthemfm and SWINIMING POOL ELECTRIC
the bass fo thealaand Profession. Any
f exempt therefrom and VALUATION
the Baan for the alleged exempts a Any ttoladA of mlty o na by any
�« appBcendredapermitsubjecblhe appllcanttoadWlperuity ofnumoreltan O117i'E7SSWI7CHESF7CIl7RFS I. 5e�b0�
q flue 1,as o nerdolof the pr. NEW RESIDENTIAL ELECTR FL
❑e as owner will
the property,or my employee with wages as their sole _SQ.FT. TYPE CONSTRUCTION
compensation,wRl dethe work and the structure b net ntended or offered for
O dile(Sec.apply
to alnow and Profeabw Code:TM lds orimpdars Llrense Law
j$$ doesoenet apply roan owner of property whonemporimprovnted that and OCC.GROUP RES.UNITS
C: wnodoesuch are nor msendedolf roffeednsigh has for owne.If,howeve,,vldedtldingh Vis
improvement issold ithindncycarferompletan,the oweveq tbderwill have TOTAL: sCA �
Improvement b sold within oneyearof completion,the owner-bullderwlll have
to rden of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEB
L as owner of the property, FLOODTDNE APN
p perry,am exclusively Buely ces and
with licensed PERMIT ISSUANCE Iq sire
contractors m construct the project(Sec J044,Busine o and of prop o Cade: 4lJs�
The Coor Improves
Llrenx Law does not apply to an owner I property with
who ALTER-DRAIN VENT-WATER(EA)
Wilds or.)License thereon,and who contra) for each plojem wIM a
Off, am
pursuant to the Convactore License Law. FEE SUMMARY
LJ I am exempt under Sec. B&P C for this..on BACK FLOW PROTECT.DEVICE !fl
•
DRAINS FLOOR ROOF,AREA,CO SANITARY Y_ N_-
Owner Date RECEB'1'R
WORK MAN I have aVSATION DECLARATION FIXTURES PER TRM aQ� SCI TA% Y_ N_
❑1 hereby affirm that I have a certl0ate of consent to seB-0nwre,or
urtifimleofWorkers'Co)pemal.onlnsuranmoraudifledcopylhereef(Sec. RECEIPT M
GAS EA. WC.40IJTLETS
3800,WbCS PARK FEE Y_ N
Colicymp Y GAS EA.SYSTEM-OVER 4(EA) RECmaT N
Company BUILDING DIVISION FEES
[�Comfied copy b herebyfurnished.the cid. GREASE/INDUSIRL WASTE INTERC R PLANCHECK FEE
�Ccrtif ed copy b filed with the dry Wpectlon division.
CERTIFICATE OF EI(EMFTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STOR,MEAl!0QFI Date ReceI t#
(TMs section need not M completed[(the permit b for one hundred dollars
(Si 00)nclea) WATER HEATER W/VIM/ELECTR ENERGY FEE Y N
Ireftlfyify that In the performanre o(the work forwNch this permit la Laved,
I shall not employ any person in any manner an as to become subject to the WATERSYSTEM/TREATING
Workers Compensation Laws of California.Date PAID
OZ Applicant
Z O NOTICE TO APPLICANT:If,after nuking this Certificate of Exemption,you NEW RESIDENTTAL PLMB. SQ.FT. Date Remi t#
Fshould become subject to the Workers'Compensation provisions of the Labor TOTAL:
W Code,you must forthwith cwnply with such provbloo or this permits hall be
> deemed revoked.
BUILDING FB a
W O CONSTRUCTION LENDING AGENCY SEISMIC FEE
aZ I hereby affirm that there la a comtructlon]coding agency for the perform TOTAL: I$ rq ELECTRIC FEE
anm of the work for which this permit bssu
issued(Sec.3197,Civ.C.)
(,) O Lender's Name PLUMBING FEE rp6
LL F- Ixedere Addrea QTY. MECHANICAL PERMIT PEE MECHANICAL FEE
O W I rertBythat l haveread theiappliationand gate lhatlhe above information
fl isoorred.I agreeto comply with all city and county ordinances and gate laws PERMIT ISSUANCE je k FEES PAID:
>. W relatingtobWldingoonstrudion,and herebyauthorlu reprowntative o(this
F Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.V Date RxeiP t# '
(We)agree to ave,lademNfy an d kee a Mea the City of Cupertino against liabilities,ydgmnnb,costs and ex sed hichmayinanywayaraue AIR HANDLING UNIT GO 10,000 CFM) SUBTOTAL:
against said City In sequen fthe gr tingefthlspermlt.
�4 - 2 MR HANDLING UNIT(OVER I0,oJaCFM) CONSTRUCTION TAX
Sigrutureof AppBant/ nirador Date E%HAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or(uture building occupant store or handle hazardous HEATING UNIT(TOI00,000BTU) Date RCCeI t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the .,
Health and Safety Cod Section 25532(a)2 HEATING UNIT(OVER 100,000 BTU) 31s�
[3 Y. I&No TOTAL:
Will the applicant or future Wlid ing occupant use equipment or devices VEN'11GTIONFAN(SINGLERFSID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air C
Quality Management4s id1 BOILER-COMP QHPOR I00,IXq BTU)
Yce No hane read the haze ous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California I{ealth&Safety Code,Sections 25505,25533 and 15534.I
understand that if the building does
notI)y haveatenanpthatitb)y NEW RESIDENTIAL MECH. SQ.FT.
respensibllity,to malty the occupantuin=ts which must be met
priortolseuanceofi Ccrtif t O
Owner or aulh rized t Date (•� ISSUED BY: r\N\v
TOTAL: J
OFFICE COPY