20434 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERhRTNO.
Building Addm,a: - I 20434
�1 S
nets ane. one: APPUCArU79CfflMrrAT A
�. CITY OF CUPERTINO-BUILDING DIVISION S'- l �—ryb
tr.d."Ni e` Nm APPLIUICATION I PERMIT l
BLDING-ELECTRICAUPLUMBING-MECHAMCAL CATEGORY CONTROL 4
rchitect/ Lk.No:
S .-_3 QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: 1 'n PERh9TIS5UANCE ❑ ❑ ❑,
LICENSED
amCONTRACTOR'SunderrDECLARATION
I hereby vciio 7000)o Divixienxd unaerpmvLaions nd Pre Chaptar9(ro,andm APPLIANCESRES[DEM1'77AL JOB DESCRIPTION
lnnowis adlon force ofd died.
Buslnens dPro(essioneCode,and my
llama Is In full fora end effect. PANELS
License Chs _aCYIle
Date Contractorraclor 1 l CwL
ARCHITECTS DECLARATION 701-1000 AMPS
0.7 plans suseas public records.I understand my hall W d blOVER1000AMPS SQ.FT.FLOOR AREA S/SQ.FT.
CO
(/ Licensed Professional SIGNSELECTRICAL
6 raw- OWNER-BUILDER DECLARATION 5I'ECIAL CERCUT/MISC
Iharebyaffuvnthat lame fromthe Contractors Llttnx Law(or the
7 O...'� following reason.(Section 7131.5,Business and Professions Code:Any city or
OMt µ9 TEMP.METER OR POLE INST.
KEg� anystm m ulostoaa permit tocomtrouirestheaprovadennlbh,orreptlr
any stmcture statement that
Issuance,also sed pursuant to the provisor ions
sofpermit e POWER DEVICES
O�� file a signed Yatement that he V licensed pursuant to the provisions of the '
µ Contractors License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
S cion 3 of the Business and Profrnion Code)orthat he Is exempt therefromand VALUATION
p yl the basis for the alleged exemption. Any violation of Se tion 7071$by any
� �5 applicant for a permit subjects the applicant to a civil pens lty of not more than OUTLETSSWITCHES.FTXTuBES
w five hundred dollars($500). NEW RFSIDENTTAL ELFATR
7 G ❑7,as owner of the property,or my employees with wages as their wk SQ. 51 FEES TYPECONS[RIICTION
compensation,will do the wdrK and the structure is not intended or offeree for
❑ sale(Sec.7064,Business and Professions Code:The Contratne,License Uw
$$ does not apply to an owner of pmpery who builds or improves thereon,and
who does such work himself or through his own employees,provided that such OCC.GROUP RIS.UNITB
Improvements arc not Intended oroffered for sale.I(however,thebuilding or L
Improvement to cold within me,year ofcompletion,the owner-buddlerwill have
to rden of proving that he did not build or improve for purpose ofsals.). QTy. PLUMBING PERMIT 'B FLOOD ZONE APN
I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
commebux to construct the Project(Sec 7046,Business and Profession Code:
The Cantmtore License law does nab apply to an owner of property who ALTER-DRAIN VENT or Improves thereon, and who contracts for such Eopjets with a WATER(EA)
cgat ct (a)licensed pursuant to the Cantradora License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
1-1 r am exempt under Sec. B k P C for this mason
Owner Date DRAINS FLOOR ROOF,AREA,CONED. SANITARY Y N_
WORKMAN COMPENSATION DECLARATION RECEPT a
`xkI hereby affirm that I have a certificate of consent to self-insure,or FIXTGRl PER TRAP SCHOOL TAX
certiflIa.�te of Workersa'�Compensation Insurance or estifled copythereof(Sep RECEIPT3800, M
t'dky Y\C��" a•'� �j �� GAS EA.SYSFEM.I INC.40UILEfS PARK FEE RECEPTX
Co�anyP .�-1 I� GAS G.SYSCLM-0VER6(TA) BUILDING DIVISIO.M1'FEES
Cetlfied co re for GREASE/INDUSERL WASTE INTERCFPT'OR PLANCHECK FEE
�Cedifled ropy V filed with the city Inspection division. '
CERTITIGTEOFEXFMPEION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
Rhissetionneedndbecomplted lftheparmlt uforoneheadrecidollars SEWER-SANITARY-STORM E.A.700FT. Date Recei tin
(51DO)rtifyt.I WATER HEATER W/VFNT/ELECTR ENERGYFEE Y N
I ll not that employ
any person
i an tm mannworker
foras to b this permit b bo the _
I shall not employ any 1eawn In any manner ao n to become mabjtt[m the
O Applicant
s'Compensatlon Iowa of California.Data WATER srsIFT,T/TEREnnNc - PAID
rap TICEt
Z NOTICEcomesuLLCAMa,Whet makingblabs Ccrti(Iate o(Exemption'you NEW RESIDENTIAL PLMB. SQ}T, Date Remi t#
Fshould become subject to the worker;Compensation provlaton of the Labor
W Code,yourrwstfort hwith comply with such provisions TOTAL:
orthis permit shall be .
w > dermad me.ked. BUI DING FE
LI CONSTRUCTION LENDING AGENCY SEISMIC FEE
= Z [hereby a(firmtFat there taaconstroctlon lending agency for the perform.
ance of the work for which this permit is ec.Issued(S 3097,Civ.C.) TOTAL: ELECTRIC FEE
0 O L,cr&ea Name FEB
LL. F I.endcrSAdaress QTY. MECHANICAL PERMIT FEE PLUMBING
O w Iantymatlhava moa thlsappinatlonand siatethatthaabove lnrormation •� ,.,�.1 MECHANICAL FEE
4 Iscomec.I agree to Comply with all city and countyOrdinances and state laws . PERMIT ISSUANCE lyLy PE CHAN
} ID
N relating to building ronstrudlan,a ad hereby authorize representatives of this
I— Z city to enter upon the above.mentiamd Property for Inspection psi rpows. ALTER OR ADD TO MECH.
— (We)agree to save,indemmy an d keep harmless the City of Cupartlno Date Receipt#
against liabilities,indgmers,costs and expenses which may In any way acwe AIR HANDLING UNIT(TO 10,ODO CEM) -
zga fret said City In consequence of the granting a this permit. SUBTOTAL:
AIR HA NDUNG UNIT(OVER 1 ILODO CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DL1Cp CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theappliant or future building occupant store or handle hazardous HEATING UNIT(70 100,00 BTTJ)
material as defined by the Cupertino Municipal Code,Chapter 9.1$and the _ Date Recei t#
Health and Salty Cade,Sction 25531(a)? HEATING UNIT(OVER 100,000 BTU)
❑ Yes ❑No TOTAL:
Will the zPP,ca` or future building occupant use equ 1pment or devices VEN'HLATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit
hazardous so contaminants as defined by the Bay Area Air
lily Management DkWt] BOILER-CAMP 0111'OR 100.000 BTU
Yes ❑ o
shave read the h.U2 materials requirements under Chapter 6.95 of BOILER-COMP(OVER IDg000 BTU)
the California Health k Safety Code,Sections 7550 25533 and 75574. Ip(�1�
understand that if the building does not currently have a tenant,that is my NEW RESIDENTIAL MECH. SQF. P a1
res onsibility to nalfytheoccupantoftherequirementewhich t brat
prio oissuanceaa Cert lateof Occupancy. 5 6 pct T Lzsai, J ?iv�J�
�` n_ I_ta 4 Lw CC !✓ ` sLl Q 1
Owner or authorized.gem Date
TOTAL: ISSUED BY:_ s t �Q cnasaC-,
OFFICE COPY