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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
BuildingPm ed Identfiotlon
Buildi ng Addrona
- F
ER
PMii NO.
19673
ame: Phone
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION /PERMIT
BllILDINGF],ECTRICAL-l'LIJMBINGMFLFiANK'AI.
pr
C Na Nn:
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CATEGORY
CONTROL Y
Arohltect/Engircer. Lie, Nre
QTY ELECI'RICPERMIT FEE
BUILDING PERMIT INFO
Address
PFRMITLSSUANCE
❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION
Ihembyaffi=m tlamlc wdunderpmvdlouof Chaper9(rommmc
Ingwlth Se .H 7000)afaid .3ofthe BuJmeuand Pmfn .Code,.ndmy
linens is In fit d affect O
LI¢n Cls Lfc X
Dat Contractor 1 S/
ARCHITECT`S DECLARATION /
]understand my phro shall be uxdupubBcreands
Licensed Pmfeabnsl
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's cerua actor's LlIAw for the
following reason. 5ectlon70715, Buslnns and Pori.ions Code, Any city or
muntywhlch requires a pemdt to ronetruct, alter, Improve, demolbh,orrepalr
uy.,cern,rreprbrmlblaenarcgaborequwtheapprcant(mauchpemJtto
Ne a aigned .statement that he is hcensed punwant to the pmv Toro of the
Contncmr'sLice. Uw(Cluprer9(commencing with Section 7000) of Divi-
von 3 of the Bualnea and PmfeJoru Cade) or that he is exempt therdcomaMVALUATION
the basis for the Oleged exermption. Any Ablation d Section 70115 by any
apphnnt fora permit subjcta the apprcant to a d") peaky d not mm tun
fav hu ndnddolla.(S.ADI.
� I, u awrcr o(the Property. or my employees with wvge u thetr Bole
rompewton, wllldothe wort &ndthe vhucturt b rrot Intended or offered for
sale C+ 7064, Buslneasand PmfessbnsCode: The ContratloraWcense Law
don not apply b u owner d Property who builds or improvn thereon,and
who doessuchworkhlmself orthrough hlsownemployen, provided that such
improvements are not intended oroffered for sale. If, however, thebuilding or
impmvenem ls.oM wilhinomyearofcompleibrl,theavner-buWld have
t4tkomienofproingthx he did rotbuid or bnpmve for purpneofaale.).
C an comer of the Property, am exchuWely osntracting whit licensed
mntraRme to corottct the project(Sax. 7DM, Bualnea aM Profeebro Code:
The Contractors Lieerue Law does not apply to an owner d property who
builds or improve thereon, and who contra for ouch prefects wteh aFEE
9,1Pcta(a)uoenaed purauant to the Contractor. L.. La w.
LI I am exempt under Sec B k P C for this reason
APPLIANCESRESIDEMPAL
JOB DESCRB'l"N
a �1
fit/ �(�jy
/�, // ���
PANELS
1-1 OOOAMI'S
OVER 1000 AMPS
SQ. FT. FLOOR EA
5/9Q. FT.
SIGNSELECTRFAL
SPECIAL CQ2CUIT/hLLSC
TENIP MELTR OR POLE INST.
IOW'ERDEVICES
SWIMMENG POOL ELECTRIC
OU TS.SW17CHES. XTURES
/
(O
M
NEN,R®FN1uL FI ,IR `�,pp_
STORIES
TYPE CON'SIRLCTION
TOTAL
QTY, PLUMBING PERMIT FEE
III'
RFS 1)MI$
PERMIT ISSUANCE
ALTER -DRAIN 4 VFM WATER (EA)
FLOOD ZONE
A['N
SUMMARY
BACI( FLAW PROTFCf. DEVICE
DRAINS FLOOR ROOF, AREA, GOND.
F1CHU PERT AP
SANITARY Y— N
RECEQ'I Y
Owner Dm
WORKMAN COMPENSATION DECLARATION
QI hereby afMn that I have • mrtlrote of conxnt to aer-iruue, fs a
¢00 Lab of Workers' Compeuati 7Insurance or • certlffed mpythercof Sec.
3800, I�bC
Poltc # %
aY
S i(X)L TAX Y— N_
RF7CF4'I' Y
GAS EA. SYSTEM -1 WG40UTLEIS
PARK FEE Y N—
RECEIPTN
GAS E.A.YST'FM-OVERa(EA>
BUILDING DIVISION FEES
ertNed copy6 hereby furnished.C
eNOed copy b flied MN the city, dlWJon.
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Thi-
TI"hla aMlmn need nor ho completed t the permr l9 fororc hundred dallan
(n ao)orlea3
I certify that in the peracen in tithework . astochtotspemdtis cLto the
I h.0mit not employ any penwa f any marrxrr,U. at u to become subject to the
WorkeA CompKnvtbn law. o(Gllfomla. Date
Appllcant
NOuking TICE TO AITUCANT: U, after nthio Certificate of aampt on, you
should become subkat to the Workers'Comprowil provisions of the Labor
Code, you neat forthwith comply with such pmvlsbru ortih permit shall be
dermed revoked.
CONSTRICTION LEADING AGENCY
Ihereby affirm that then Is a rorotmction lending agency for the perform
ante of the work for whkh thio permtt ts Loved (Bee, 3097, Clv. CJ
tenders Name
I.ender;Addrcsa
I certifythat l Tuve read this application and etatethat theabove Bdor dun
Ls mrect. l agree to comply with all city and county ordinances and late laws
relating to building comtructim, and hereby authcr mprnentative of this
my to enter upon sthhec abavrmentbrnd pmperty for Wpectbn pup.,
(We t ,bdemnify an dkeep lcJ, the Cryof yw.y.rtino
ge 10tc Igmen t meta. epenaes Wmaylnuywayamue
age dC1 osnae root&ming thio pemJt.
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
—
Date Reoel t#
CREASI�TRAP
EA. 20Dr1.
WATER HEATER W/VENT/ELDM
ENERGY FEE Y_ N —
PAID
Date Recei t#
WATER S,S.�/TREATING
NEW RESIDENTIAL PLh1B. SQFI.
TOTAL:
BUILDING FEE
TOTAL
SEI MIC FEE
t
ELECTRIC FEE
QTY. MECHANICAL PERMTT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
ALTERORADD]OMECH.
FEES PAID:
Date Recei t#
ADt HANDLING UNIT (10 10,0WCM
SUBTOTAL:
ALR HANDLING uNrr (OVER 10,()()(3 CFM)
CONSTRUCTION TAX
r
SI lure of Apprcant/Contract Date
HA RDOUS MATERIALS DISCLOSURE
Will the applicant« future building occupant store or handle haaardms
nuterhl a de0rcd by the Cupertino Municipal Code, Chapter 9.12 and the
Ile.kh,M Safety Code n2S532U)r
❑ Ye No
Will theapplicart or tore building p..t use equipment or dewims
which enrt mntaNruntau defined by the Bay Area Air
QualXy Management Eh riqt
4 °
h.vercad the havr s materials requiremens underChapler 6.95 of
G
the lromla Health k Safety Code, Sections 25505, TaS73 and 755.74. I
unci andt1w ifthebu0dingdonnotmrtentlyhave&tenant, that lth my
res ro 11hylonottheecmpan theregWrememawhkhnanslbemet
PH rt an. ahiO spa ry.
EXHAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT(IO100,000 BTU)
Date Recei t#
HEATING UNIT (OVER 100,0W BTU)
TOTAL:
Nso
VFN]ILATION FAN (SIN= RESLD)
ISSUANCE DATE
ApilA7N,lf��J ,
cJ`J- V
a��,,a�__�,aa�_�
LSSUEDBY:aa CST-' firsF.)...lJ���IV�
BOILER -COMP 0HP OR 100,000 BTU)
BOILER-COMP(OVER 100,000 BTU)
NEW RESIDENTIAL NECK. SQFT
mer or author dagent to
TOTAL:
OFFICE COPY