22576 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: f'I f'1
7631 k. GG
wen r• ams. - one: 576,-
A
MA ver- CITY OF CUPERTINO-BUILDING DIVISION
Contra�p('s nc Lie.No: , .-APPLICATION/ PERMIT Q L
U-
BUILDLNG-ELECG RY
TRICALGM
PLUMBINMFLHACAL 7T1'A C O NTROL(✓/. D
' Arehitect/Enginrer. Lk.No: b O
',.BUILDING PERMIT INFO,
QrY -.ELECTRIC PERMIT PEE
Address: PERMQTISSUANCEPeo r�g'
LICENSED CONTRACTOR'S DECLARATION r�g1!!:N ,
I hereby affirm that l am licensed under provisions of Chapter9(cemmrn APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwith Section7000)of DiWslon3olthe Businessand Pmfesslom Code,and my s
line-,is ie full fans and effect S
PANEO
LI-me Class LM.# I
Date ' Contractor
ARCHITECT'S DECLARATION 201-1000 AMPS
pctO Zp I understand my pians shall be used u public mcmda. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
SIGNS ELECTRICAL 'I
hG (/ Licensed Professional
OWNER-BUILDER DECLARATION SPEC)AUCIRCUIT/MISC v
7 � I hereby affirm that l am exempt(romthe Contractor's License Law for the -
QQ loVOwing reason.(S floo 70315,Bushuminl Professions Code:Any city or 000
F'•s' TEMP METER OR POLE[NST.
countywhlchrcqulmaper ttommtrod,altegimpmve,demolbh,ormpalr
any structure prior to its issuance,alsorequirestheapplimntforauchpermltto 1
//11
file a signed 4alement that he b limnsed pursuant to the provblom of the IL')WTiR DEVICES / /��• rJO
Contractor's Lice Law(Chapter 9(commencing with Section 7000)of Divi- CCJJ G.
�O"J ef.n3 f(oh1 Budnceaard ProfemlomCode)orthathebemmpttherefmmand SWIMMING POOL ELECTRIC VALUATION
the Web for the alleged exemption. Any violation o!Stolon 7001.5 by any appBmntfera permit aubjedstheapplicam loacivll penalty Ofnol momth.. OUTLETSSWI'TCIiFSFIXTURFS 1 ,
6
five hundred ($500).
❑ NEW RESIDENTIAL ELECTR SQAT. �E�� ® T ONSIRUCTION
QQQ �n 1,as owne.rrof.ftars the propedy,or my employees with wages thele sole
compenution,wllldothewoek andthe etrocture boot Intended orr offered for
O sale(Sec.7041,Buelnsssand Pro(esslom Code:The Contndera Llceme law
does not apply to an owner of property who Wilde or improves lhersory and C ITS
CC.• whodousuchworkhimselforthmghhlsownemployeesprovldedthatsuch
Lnprovemenbamnotintendedorofferectforsale.Ifhmevepthebulidingor r TOTAL.imp.enma bsold withinoneyearofcw
ompletion,the oner-bulleterwlll have v
Hie k:rden of perving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT '
L_J L as owner of the property,am exclusively mntrading wllh licensed
mnt-xT to construct the pro)ed(Sec.7044,Rosin, end lsro(essbm Cod e: PERMIT ISSUANCE
77re Contractor's Linens,Law does not Apply to an owner of property who ALTER-DRAIN k VENT-WATER(FA)
Wilds Or improves the.,and who contract, (m such p(ojects with a - r
},�Ltjactor(e)if...d pursuant to the Comrseles Llmnee Law. - FEE SUMMARY '
L�1 am exempt under Sec. B k P C for this reason BACK FLAW PROTECT.DEVICE
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N '
at. RECFR'T#
WORKMAN COMPENSATION DECLARATION Fp((URpg PER TRAP /k SCHOOLTA)( Y_ IN
❑I hereby affirm that I have a certificate of consent to se161nsure,or a LSft— RECEIPT#
380,Lab C.Workere Compemaeonlmunnm ora cedi(ied copy thereof 6e<. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE ' Y N
Polis Lab Cd RBC Policy Y GAS EA.SYSFEM-OVER 4(EA) M
Com any - BUILDDINGING DIVISION FEES
r5Certified copy Is❑ herebyfurnished,the city
Certified copy b filed with the city impecdan division. CRPASE/IIDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP i PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date Recbi t#
(this rection need not W permit If the pedt b forone hundred dollars
($100)metify that
WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
Ill not 1Fat o the person I. ofthem work.As t b co permitbissued, 3a„/1
I stall not employ any person In any manner at u to become subject to the WA PAID I j fY
Workera'Compenutlon laws of California.Date PAID
O Z Applicant Date Recel t#
.Z Q NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.FT.
should become subject to the Warken'COmpenutlon provisions of the Labor 'TOTAL:
N Cade,you mu at forthwith comply withsuch provlalmamthis permltehall he B E
deemed revoked.
W C CONSTRUCTION LENDING AGENCY - - "SE MI
d Ihereby affirm that them is a mulmetion lending agency for the perform- )ELECT E
Z ance of the work for which this permit is fmued(Sec.3097,CN.C.) - TOTAL:
(� O Iender'e Name PLU G EE a
LL F Lender'sAddres, QTY. MECHANICAL PERMIT FEE ANI FCC
O W ImdlfIethatlhavereacithbappllmtionandstmcthattheaInmemformaJon
'sneered.i agree to comply with all tltyand county Ordlnaeces and state laws 1 PERMIT ISSUANCE SPAID:
>- C construction,relating to buildingconstruction,and hereby authorlse representatives of this Y-l+��e�� -
F N city to enter upon the above-mentioned property for inspection purposes., ALTTRORADDTOMECH.
Z (We)agree to save,IndemNfy and keep harmless the City of Cupertino - Date Reaei t#
V against liabilities,judgments,costsand expermawhich may In anyway accrue AIR HANDLING UNIT(T6 t0,000CPM) BTDTAL:
against mid City in mmce a equengrantingof this permit.
q/ AIR HANDLING UNIT(OVER IOfifit M) CONSTRUCTIO TAX
urs of Appleant/ or DUe `� oa1AD57 Hoop(w/DDC'n '- CONSTRUCfIO TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or few.building Occupant,forcer handle hazardous HEATING UNIT(TO 10,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 933 and the Date CCCIht _
Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 10,000 BTU) TA
❑ Yes ' I No -
Wllltheappilcar'na turn building occupant use equipment or devices VENTILATION FAN 6INGLE RESID) ISSUANCE NATE'
which emit hazardous air contaminanbudeflned bythe Bay Area Air
Quality Management District? BOILER-COMP OMs OR IOO,WO IHU) S� -
( q Ye, 9 No
haveread Healthe h
ar Safety
m ode,Sections
2555,2553 and 2S5r5.9S of BORER-COMP(OVFR 100,000 PTU) -1 �j ('�
theGllfornla Health&Suety Coes Sed1ountly have
a tennd255atIt - _ PCT }, V `991
understand that iotIfybuildingthe
doe,oft , getyhavea tenant that It Is my NEW RESIDENTIAL MCCJi. SQ.FT. ,
mor to Issa c of a Certificate
of of the mqulrcnrntswhkh most be met s y
prior to issuance cats Cedllkate of Ocmpanry. wy Q!
Owner or authorized a gent Date ISSUED
TOTAL:
OFFICE COPY