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19751 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PERMIT NO. Building CM =5 E n �r SUI(1 g 19751 A A nen w Ae Phone: A 4 I5 01 �87�38kY CITY OF CUPERTINO-BUILDING DIVISION c°`n''l" ' n.: LI APPLICATION / PERMIT C9 W S 6uuwoly cow wr 4Sb to BUILDING-E'LECTRICALMLTMBINC-MECI LAICAL CATEGORY CO Architect/engineer. Le.Nee /- S Ss C7Cr QTY ELECTRICPERMIT FEE BUILDING PERMIT IN O Address: PERMITISSUANCE 1:1 [_1 ❑ LICENSED CONTRACTOR'S DECLARATION Ihereby affirm that l am Bernard under provisions,of Chapter 9(commec- APPLIANCESRESIDENCIAL JOB DESCRIPDON Ing with Section 7000)of Division 3 ofthe Business and Prolessiom Code,ana my license lain---force anaeruct. PANELS License Clam Lk.s Date _—Contractor Contractor ARCHITECTS DECLARATION 201-1000A.MPS m0 Z I understand my plan shall baus,d e public records. OVER 1000 AMPS SQ.Fr.FLOOR AREA $/SQ.Fr. O Q zto Wcenud Profemiorul SIGNS ELECTRICAL 6] OWNEReBUILDER DECLARATION SPECIAL CIRCUIT/MLSC 7 f'a� IherebyalRrmthatlamesemptfromthe Contractors License Lw(m the F f '§ following reason.(Section 70315,Business and Professlons Code:Any city or countywhichrequ( apermittocomtr d,alter,lmpmve,demolbh,ormpair TEMP.METER OR POLE INS-. I anystructure inform its Lsnaance,also requires theapp-cant forsuch permltto � c.6 flea signed atatecomt that he b Ilcensed pursuant to the provisions of the POWER DEVICES 3 r.. Contractors License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC O sion3 ofthe Busines and ProfessionsCode)orthat he bexempt thercfromand VALUATION f. Y.'g the basis for the alleged exemption. Any violation of Section 703tS by any 05J applicant for a permit subject the applicant to a civil penalty a ns,morethart OUTLETS-SWITCHES-FIXTURES 1 ©O live hundred dollars($500). l �n ❑I,as owner of thNEW RESIDENTIAL ELECIR e property,or my employees with wages as their sole e"Q'�' SfOI TYPE CONSTRUCTION �/-6 compensation,w111dothe work andtheswRure snot Intended orof(end for 5 O sale(Sec.704k Business and Professions Code:The Contractor's License Taw I,TS$ does ns,apply to an owner of property who builds or improve thereon.and who doessuchwork hinvelforthrough hisownemployees,provided that suchOCC.GROUP __M UNITS improvement arc not Intended oroffered for sale.If,however,thebuilding or TOTAL: improvement issold withinoneyearofcompleWo theowner-bu0derw111 have tlA.�vrdan of proving that he did notbu-dorlmprove(orpurimeofsale.). QTY, PLUMBING PERMIT FEE LI I,as owner of the property,am exclusively contracting with licensed F1.00D ZONE APN contractors to comnvct the project(Sec 7004,Business and Professions Code: PERMIT ISSUANCE The Contractor's License Law doe not apply to an owner of property who bu7yTEKDRAIN&VENT-WATER [EA) Wilds or improe contracts vthereon, and who contfor such EVoM - jewith a C tt aever(s)licensed pursuant to the Contractors,License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY LJ I am exempt under See. B&P C for this reason OwnerDRAINS FLOOR ROOF,AREA,COND. SANITARY Y N Date R��,R WORKMAN COMPENSATION DECLARATION 1 hereby affirm that 1 have a certiBate of consent to self-insure,or a FIXTURES PER TRAJ' 951001,TAX Y N cerci care of Workers'Compensatlon Wuanceora cerifled copy thereof(gee. RECEIPT# 3800,LabC) GAS EA.SYSTEM-11NC4 OUTLETS PARK FEE Y N Pmliq Y E�Y,.'p,g ..� ys. �� RECEIPT M Co a �Y` ,d. s'a-Nr •1 1 GAS EA.SYSTEM-0VER4(EA) BUILDING DIVISION FEES �CertlRed copy Ls hereby furnished. 5-&LCerti(icd copy ufiled with the city inspection division. GREASE/WDUSIRL WASTE INTERCEPTOR PI.ANCI-IEGK FEE CERTIFICATE OF E%EMPOON FROM WORKERS' GREASETRAP PAID COMPENSATION INSURANCE / /yt (This section need nm be compleed If"permit isforonehundreddollam W SEER-SANITARY-STORM EA.20OFT. Date Recei O S(a0 (5100)m Iess3 Icertify that in the performance of the week for which this permit is bored, WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N I shall net employ any person in any manner an as to become subject to the Workers'Compensation Laws of Caliromt.Date WATER SYSTEM/TREATING O PAID 7r Ra_ .���- Applicant NOTICETOAPPLICAM:If,agermakln this Certifiateof Ex em tloq NEW RESIDEM7AL PLMB. p g p yrs- —sQRr. Date Recei t# ciaoo N should become subjectto the Workers'Comperention provisionsorthe Labor TO ~ Code,you resat forthwith comply with such provisions orthis permit shall be TAL: mre LU > dermad invoked. B UILDINGE a p CONSTRUCTION LENDING AGENCY I hereby affirm that there Iii.comtruction lending agency for the perform- FEE 7 Z ance of the work for which this permit b issued(Sec.3097,Civ.C.) TOTAL: 0 2 Lender'eNamr � FEE LL F [cndmis Address QTY. MECHANICAL PERMIT FEE AL FEE O W Icnrtl(ythatl have read thisapp-atmnand oatethatthe above information 1 iscorrect.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE rrelatingtobullding cormlructice,and hereby authorize represenativeo(thiscity to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. (We)agree to save,Indemrdfy an d keep harmless the City of Cupertino Receipt# against liabilities,judgment,costs and expenses which may N any way aaxue AIR HANDLING UNIT(To 10,M0 CFM) against said City in conslgO ence of the gram ing of this permit. SUBTOTAL: AIR HA NDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX Sigoawreof Applicant/Contractor Date D(HAIIST HOOD(W/DUCT) CONSTRUE TIONTAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle haaamlous HEATING UNIT(TO 100,000 BTU) material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the Date RCYei t# Eicalth and Safety Code Section 25532(a)9 HEATING UNIT 100,000 BTU) TOTAL: ,a ❑ Ye yr�yrl No W-Ithe applicant or(Lturc building occupant use equiponom or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE which emit hazardous air contaminants as defined by the Bay Area Air Quality Management rct7 Ye BOILER-COMP DEEP OR 100,000 BTU) a�u ,�. q, read the hara if d,Setions 2mrnt5533 and 255 .1 of BOILER-COMP(OVLR 100,000 BTU) theerstand that if the have a Land,that it /fRt �7 understand that Bthf theongdoe Oft a requiyhaveatrnant,that he et NEW RESIDENTIAL MECH. SQ.}T, reurto issuance ofa throats of cetherequlrcment which must be rant U prior to issuance o(a Certificate of Occupancy. i /az-l"o .M ``✓ Owner ora heeled agent Data n/pla.'17i ns� � TOTAL ISSUED BY: OFFICE COPY