21076 'APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification - - PEIMT NO,
Building Address: -
�o►ao -C 6In"',k� 21076 .`
- wners aces: - ora:
MEasLLRSX CITY OF CUPERTINO-BUILDING DIVISION
Contractor. p
.Name: p LIe.No: APPLICATION / PERMIT I
ELGC \ Q. SOCq BIRLDINGF�.ECTRICA4PLUMBINGMECIIAMCAL CATEGORY CONTROLN
Arcjl : ginsr. Lk.No: •
1 (� QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
111,� ELELI PLUMB MUCH
Addrse�520t WcF'�YgTra sr S. C. PERMRTISSUANCE 112 .,
LICENSED CONTRACTOR'S DECLARATION
I herebyefflrmlhat lamllemued under provisions o(Chapter9(commrnc- APPLIANCESRRSIDENTTAL JOB DE 1(11'I70N
Ing with Secllmn7l7(D)of Dlvlslon3 ofthe Buslnessancl ProfesimuCode,and my
Iicanea is In(ullfO deffeR. p 1 PANELS -
Licen�cClamS.=1SLLlc.p 5d�-Igo
naie_7_Za_9 Q_cnntractor--rar u—isa 4ffT'—LCTO 200AMPS—112
ARCHITECTS DECLARATION 201-1000 AMPS
qK 2 I urelimand my pbm ahaB be used s public record. OVER IODO AMPS SQ.FT.FLOOR AREA $/SQ.FE
000,
Licensed Profestimid SIGNS ELECTRICAL `
dd ul OWNER-BUILDER DECLARATION
SPECIAL CB2CUIT/M
7 p„vl 7 hereby a(Ortn that I am exempt from the Cantraeorb Llcens Law/or the _
pQ following reaaon.(SMion7031,5,Business;and Professions Code:An cityor
P,iQ9i countywhich myuirs a permit tocorutmct,alter,bnpnsve,demolish,Any
7FMP. METER RPOLEI a, y
r anystmd..prtortoirebmance,alsorequlmtheappBantforsuchperMtto
le a signed statement that he is,licensed pursuant to the provisions of the POWER DEVICEF
OwG Contractors License Law(Chapter 9(commencing with Section 7000)of Dial- ' ^'• 'r ��
HBO eion3ofthe Buslntnea.d Prefevomu iCale)or that he b exempnhemfmen and SWTmMING LELEC6CVALUATION
'S the Web for the altegedexemption, Any violation of Section 70)1,5 by any a a -
G05 appllant for a permit subjects the applicant to a civil penalty of not more than nq�• TCHFSEXTI MRS
fivoundred Lj1,asowne of Ihepr. ! NEWRF9 ENTIALEECIR SQ.FT. - STORIES �TYPE CONSTRUCTION
u I,aeownero!the work,a,orhe employeswithwages FtWitso
a compensation,Buslevwill tWwork endthertmcte:TheCure is him Contraintenctors
Llcarjr La .
$ O sale(Sec.7044,Butlnes and Professions;Code:The Contractors Lkerue law ,
5$ does not apply to an owner of property who builds or improves thereonand OCC.GROUI'. RIS UNITS
who does such work himself orthrough his own employees,provided lha!such
Improvements am not Intended proffered for sale.If,however,the bull, sir - TOTAL:
improvement bsold within oneyearo(mmpletlon,theowner-builderwill have
t burden of proving that he did net build or Improve for purpose ofu a. QTY. VANCE
PERMIT FEE FLOOD TONE APN
LJ L ae owner of the property,am exclusively contracting with PERMIT
contractors to construct the project(Sec 7074,Business and Professions Code:
Tha Contsctor's Li...Law does not apply to an owner d property who ALTER-DRAIN&VENT WATER(EA)
builds or Impruvn •
thereon, and who contracts for such p(ojects with a FEE SUMMARY
Off,
licensed pursuant to the ContvEtoes License Law. BACK FLOW PROTECT.DEVICE
I_I I am exempt under Sec B k P C for this mason
OUTSIDE rFrq
Owner Date
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
WORK MAN COMPENSATION DECLARATION RECEIPT NFIXTURES PER TRAP SCHOOL TAX Y N
hereby.(firm that I have a certlRate of consent to self-Insure,or RECEIPT N
rtl rate o(Workera'Comperuatlon Insurance oracertified copy thereof(Sec.
3800,Lab C.) CAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
Poll M GAS EA.SYSTEM-OVER RFCI]PIN
A Com any BUILDINGDIVISION PEES
Unany
copy b herebyfurnished.the cid. GREASE/INDUSML WASTE IN'1'FRCE'TOR PLANCHECK FEE
141 Certified copy b filed with the city Inspection division,
re'y CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID .
COMPENSATION INSURANCE SEVER-SANITARY-STORM EA.20011T. Date Races t#
(fhhteneed not Wcompleted lithe permit b(oronehundred dollars($1I curtlem.)
s0 WATERFrEATFRW/VENT/ELECTR ENERGY FEE Y N
Icertifythat In the per(omunce of the work(orwhkhlhie permit Is Issued, —
I shall not employ any person in any manner an a to become subject to theWATER SYS'1'F2x1/TREATING
workers'compensation laws of California, Date PAID
licant
Z O2 NOTICE TOAPPLICANT.B,after making that Certificate ofExemption,you NEW RESIDENTIAL ELMS, SQFF. Date RL'cei t#
Hshould becomeeubjecl to the Workers''Comperwtion proWiom ofthe Labor TOTAL:
W Code,you must forthwith comply withsuch provbimumthb permitshallbe FEE
BUILD C
W ] ci meed revoked.
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there b a construction lending agency for the perform- ELECTRIC FEE
Z ante of the work for which this permit is Issued(Sec.3097,Civ.C.) TOTAL:
VO Lender.N.me - PLUMBING FEE
LL I..dcre Addmss QTY. MECHANICAL PERMIT FEE MECHANICALFEE
Icertifythatl have read thisappBstion and statethat the above information
O W
1 Incorrect.7 agme tocomply with all dlyand county ordinances and stale laws PEBMTTISSUANCE; FEES PAID:
>. IL construction,and herebyauthorize repersenstiveeofthis
Zcityto enterupon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
z (We)agree to save,.Indemnify'an d keep harmless the City of Cupertino Date- Recei t#
against liabllitlea,jtdgments,costsand expenseswhich mayin anywayaccem AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL:
agaiat said City In consequence ofthe granting ofthls permit. ,
_ AIRHANDUNG UNIT(OVER 10,WDCFM) CONSTRUCTION TAX
51 natuea of Applicant/Contractor , Data - EXHAUST HOOD'(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,OW BTU) Date RCCCI I#
meterlal as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety C a ctlon 25532(.)7 HG'NIG UNIT(OVFR 100,000 BILI) TOTAL:
MY. . o
Will the ppllant oMmm building occupant use equipment ordevlcs VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contammants as de0red by the Bay Area Air
Quality Management District? BOILER-CDMP(3HPOR 100,OW BTU)
qYn
have read the bars out mdteilab reciammenbunderChapterf,95 of BOILER-COMP(OVER 100,000 BTU) •"'a-Y � � 199Y'
the California Health&Safety Code,Sections 2550.5,25533 and 2:537.7 $�+%
understand that if the building dos not currently have a tenant,that it is my NEW RESIDENTIAL METH. SQ.FT. '
rspoembllity to notify the occupant of the requirements which mu at he met t t
rp for to Issuance of a CcrtiOate of Occupancy. Ira 47{p
Od(vner or authorluagent Date - L7_ ►J1101@{ '
TOTAL: ISSUED BY: rVV((�J� jjWWnff
OFFICE COPY