21768 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES = USE BALL POINT PEN ONLY
On Ilding Profen identification PERMIT NO..
Belding Add;Z
-7Sss HaA E-ml000 ba - CUPcRtINO 21768
nen ame: one: A
d- ELIZABETH 13UcleEL CIN OF CUPERTINO-BUILDING DIVISION /)0
con...toe.N.me: n: APPLICATION / PERMIT
l , N elf�2tsEs ;Lc)-7 ILb.N 6
BUILDINGELECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL N
Archltet/Engineer. Lk.Na,
/von/
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:
LICENSED CONTRACTOR'S DECLARATION
oPFRMITISSUANCE ;uc �IMremthnlaivgcensed underpnso(Ch 9( mOAPPWANCESRESIDENTIAL
1^8wRASvCtI0n700)af DlWson3c,fthe9uslnexxordPre(eson.e.Cde,and my JOB DESCRIPTION
❑
Icenac is In ful force end effect PANELS Itemovc- NON— (3tARina
Date C n — Ic Y a 715 6 $ L✓tYt, 10A—ft—r, A/-
Dale 6L Cont ador
ARCHITECrS DECLARATION
Get`/. 2Bvl000 AMPS N N CL oS t 7—
a0 O I understand my plana shall be used as public record+. VER 1000 AMPS - .n - . R'rjA�
;' I,
� s/SQ.FI..
License
d Prefesomal GNS ELECTRICAL !" !�
7�'G-y��yuuyy OWNER-BUILDER DECLARATION T E R
� Ihercbya(firm thatlam exemptfromthe Contractors Llcen.e Law forthe SPFCIALCIRCUIT/MISSC {. ' 1 I
following reason.(Se tion 7m1.5,Business and Professions Code:Any dty or 2//�/�
pig muntywhich requlrna Permit to construct,alter,improve,demolbhor repair "�TFMP'METE20RPOLEINST. )
q nyatmttvre prbrrolb iswance,aborequlreethe appliant(or each pemcb,to POWER DEVICES I
t-"p�LQj file a sigied statement that M p Ilcensed pursuant m the pmvlsbv of the
�Wj 3 Otr, Contnttore Llcerus law(Chapter9(mmmencing with 5M1an 7000)of DIN- NG POOL ELECTRIC
sion3of 1he0usineasand Pro(enlaro Code)orthat hebesempt therefromand VALUATION
the basis for the alleged exemption. Any vlolatbn of Section 70)1S by tlun any �.OUILETSSWITcHmFIXfURES W
O appgontfora permit subjects the applicant too tell pevlty ofnt rtnrc ( � QQba ate/
py five hundred dolWa($50�. NEW RESIDENTIAL ELECTR
Q•-�n �I,as owner of the property,or my empbyea with wages ea their wle —SQFL STOW FS TYPE CONSIRIKTION
Ocompensation,wflldothe work+ndthe stmtture b not Intended or o((emd for
aaie(See 7044,Buslrienantl Pmfenloru Code:The Contnttors Llceuc Law L-LU CATS _ ISTIN OTLET
HE dom not apply to an owner ofproperty who Wilda orimprovn thereon,and RELC
OA
HE whodoessuchwarkhimeelforthwgh hiaownemployees,pmvidedthatsuch E)<tmu LU• OCC•GROUP RES.UNITS
Improvementsaredwithinded earofred(orale.thhowever,thebuildlegor TOTAL:
Improvementbwid wlthlnoneyearofcompltlon,theowner-bWiderwllihave
ttill.liundenaf pmvingthat he did not WlldmmIp.v.forpurpose.fuI,.L QTy, PLUMBING PERMIT FEE
Lj L as owner of the property,am exclusively contracting with Iimesed f'7AOD 7DNE APN
corbstorsto co st of the project(Sec.7044,Business and Profentoru Code: PERMIT ISSUANCE
The Contractor'.License Law does not apply to an owner of property who
Wilds or improve.thereon, and who contnts for such plojets with a ALTER-DRAIN&VENT-WATER(EA)
torts)licensed pursuant to the Contractor's License Law. FEE SUMMARY
I am exempt under Sec. B&P C for this reason BACKFLOW PROTECT.DEVICE OUTSIDE FEES
Owner Date .C+ DRAINS FLOOR ROOF,AREA,COND, SANITARY Y N
WORKMAN COMPENSATION DECLARATION RECEIPT N
541 hereby affirm that I have a certlficete of consent to u161nsure,or a FD(TURFS PER TRAP (.t-CIOSCHOOL 7A% Y N
ceti0nte of Worken'Comperwtlonlruurmmora artlfled copy thereo!(Sec. ` RECEIPTN
3800,Lab C,) GAS EA.SYSTEM-1 INCA OUTLETS PARKpEE Y•_ N_
PolicyN 06 _
�'GAS PA.SYSTFMAVER 4(EA) RECEIPT Y
C,o�mp ray ) Z BUILDING DIVISION FEES
I.ACertifi xl copy la hereby th the cid.
Cenlied mpyb Ned with the city inspection division. REASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
Crhis section need net be completed if the permit is, SEWERSANITARY for onehund red dollars SIORM EA.20(IFL Date RBcei t#
ailw)m len.)
Icertlfythat In the Perfermanceofthe work forwhich this permit is based, WATER HEATER W/VENT/EI•ECT'R ENERGYFEE Y_ N
1 shag not empty any perwn In any manner at as to become objet to the
Worlicrs'Compenutbn Gwe of Glifomla.Date WATER SYSTFAI/TREATING
O Z Applicant PAID
Z O NOTICE TO APPLICANT.if,after making this Cetl(kateof Exemption,you NEW RESIDENTIAL PLMB.__SQFE Date Recef t#
should become subject to the Wmkers'Campetmatlon provisions of the Labor TOTAL:
N Code,you most forthwith mmpty with such pmvbiom or this permut shall be 5 A O L` E)C llirlN Cn
W > deemed revoked. BUILDING
FEE
a p CONSTRUCTION LENDING AGENCY UPPL (-IVES •TD (UPP6-(1- SEISM IG FEE ZY I hereby affirm that there be construction lendingagency for the perform ELECTRIC FEE
Z ance of the work for which this permit is Issued(Sec.3097,CIv,C.) TOTAL; / s�
U Lender.NameAddy u PLUMBING FEE Qd
LL F lenders Address qn. MECHANICAL PERMIT FEE
O W 1cetlfythatlhave readthbappllotlonand tatethaltheebove information MECHANICAL FEE
IL bmrmd.I.greetocomply withal city and county ordinances and tate laws PERMIT ISSUANCE FEES PAID:
N relating tobullding corstrotion,and hereby authortee repreeentatives of this
Z cityto enter upon theabve-mentimied property for Inspection purposes, LTER ORADD TO MFCH.
— (We)agree t rave,Indemnity an d keep harmlessthe City,of Cupertino Date Receipt#
ag.had bbtiit ledgggPPP nts,cost sandexpense.whichmaylnanywayacwe RHANDLINGUMT(TO10,000CFM) SUBTOTAL•
.9 ,i3l c6nj�quena o(the grenting of this permit
<//)('rAQV l AIR HANDLING UNIT(OVER I0,0DOCFM) CONSTRUCTION TAX
Slg reof Applkant/Contractor° 1 Date E%HAUSTHOOD(W/DUC:T) CONSTRUCTION TAX PAID:.
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fulurebuilding ottupant stomor handle harardous TING UNIT(TO 100,ODO BTU)
materiel as defined by the Cupertino Municipal Code,Chapter 9.12 and the _ Date Recei [#
I le❑alt sed Safety Cod ee Section 25SM(a)I EATING UNIT(OVER I W,000 BTU) TOTALyes :
Will the applicant or fu to bulldingompant use equipmentardevnes VENILATIONFAN(SINCLERESID) ISSUANCE DATE
whkh.Mt luaardous a4 mntamiunts as defined by the Bay Arca Air
Quality Management District? &46OILER-OOMP OEI'OR 100,000 BTU) IDA I
Yes II��No FSM
Gave read the haz.9 us mabrials requimments under Chapter6.95 of1;W
the Glifornb Health&Safety Code,Sections 25505,25533 and 25534.I
understand that the building does not currently have a tenant,that it is myT
responsibility to notify the occupant of the requirements which must be met
pdorm Lssuanm ofa Certlfkate of Occupancy. �
Owner or authorlud agent Date
1 ��@ISSUED BY:
OFFICE COPY