21080 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification - PERMIT NO.
Building Add res: 2�1 O^O
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nere ante: one:
s'�vsr.9yTz y� CITY OF CUPERTINO-BUILDINGDIVISION
Contactor.Name: Lic.N. APPLICATION / PERMIT
Architect/Enginrer. Lir.No:
BUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL N
'
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Adtlress: - PERb1ITISSUANCE g
ereby LICENSED CONTRACTOR'S DECLARATION -
IhthSwiRbmthatl ivisi=3oftheunder provldonse(mioner9de,and APrLIANCFSRESID7iNfIAL JOB DESCRIPTION
i�gwi11...hSection 7000)of d effect.
Bualneaand Pro(ealannCode,and m
license Is In full cores And effect. PANELS
LluneeClau GcI / ��Ir Cel
Date Contractor UP TO 2DO AMPS
701-1000 AMPS 1 (lV
ARCHITECPS DECLARATION OVER 1000 AMPS II SQ. - S/SQ.FT.
q�q�uu otO Zp l understand my plan shall be used as public remrtls YLS
Licensed Professional SIGNS ELECTRICAL"
6 g OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC
7F, Ihereby affirm that l am exempt Isom the Contractor.License Law for the
p following...(Senlon 7031 S,B.M.A.and Pmfesbns Code:An city or, 400 �7 D
03 o ty TEMP.METER OR POLE INST. t�
Any structure
requlresaperMtto core truss,albnlmprovgdennlbh,ormitto
g any awturetatemettahat he isalas sed PUTtheappthe ro ouch ions of cite . POWER DEVICES
E9� the a signed statement that M b licensed pursuant to the provisions of the
G673µ,1I-. Contadoes License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC UA
t,�OJ siod3 oftheBusinss and ProfeslonsCode)orthat he is exemptthercfmmand VALTIONa
.•77 the basis for the alleged exemption. Any violation of Sertlon 70715 by any OVILE7SSWI7'CHESFIXTVRFS r D v Q Q v
poppBmntfonperndtaubjectatheapplicanito,,I lINmltylna malhan
M
rdooddallaa(5500), SQ, STORK TYPE CONSTRUCTION
�nk(6nl�c NEW RESIDENTIAL ELECTR Fr,
Lasownerll theproperty,orhe employeswithwages r thelesok
rotation,Soul.. work, ie not Intended or Law
O sic(Sec.apply
to Alnen andf property Code:The Contractors Lintaslaw
$ dos not a.plytoAft owner orthmu hhis o nempiuilds rne,provided
ro ided that
and uch OCC.CROIIP RES.UNITS
wprove mchworkhimeended orough hlnowne.If,
however,the
midi gor
improvementearcnotinlended earofcompidroffered for io.i ho neer-buUderwdI have TOTAL: it.�
Improvement.sold withinoneyearofcompldlorytheowner-bullderwlll have
t"nien of proving that he did not build or Improve for purpose orale.). QTY, PLUMBING PERMIT FEE FLOOD WNE APN
LJ L as owner of the property,am exclusively contracting with licensed - PERMIT ISSUANCE
rontadare to construct the project(Sec 70M,Business and Profesiuv Cade:
The Contactors License Lw don not apply to an owner of properly who pLTIRDRAIN&VEM-WATER[EA)
builds or Improves thereon, and who contracts for such p(ujecta wit .
h a FEE SUMMARY
nPif!ctor(s) need pursuant to the Contratw' Liceaae Law. BACK FLOW PROTECT.DEVICE
(_f I m xe pt uncle ec B&sP CC.l'tht�hi_n/rcJaJ'.sa�n
Own Date Nr/ ._' / - DRAINS FLOOR ROOF,AREA,COND. SANITARY Y . N_
rF A RECEIPT 0
VOR 011 MP aNSATION DECLAR 10 Irl)(TUNE4 PER TRAP SCHOOLTAX Y_ N_
L,Khercby affirm rkero that I have o certificate of consent to copy
thereof ora RECEIPT X
cedBlcab o(Worken'Compewtlan Wuranceora certified copy thereo((Sec. GAS EA.SYSTEM-11NG<OUTLETS PARK FEE Y N
3800,lab C.)
Policy p - RECEIPT N
Cany CAS FA.SYSTEM-0VER4(FA) BUILDING DIVISION FEES
omnCedNed copy is hereby te city
nCertltled ropy b filed withh the alty inspectionectlon division. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
ly
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SAN17'ARY-STORM EA 700Ff Date Recei t#
(Ihlsxectirm need not be cornplted if the permll bfm one hundred dollars
(51les.)
I cemlythat In the petormancearthe work forwhlch this permit.issued, WATER HEATER W/VPNT/ELFC7R ENERGY FEE Y N
I shall not employ any person 1n any manner an As to become subject to the
WATER SYSfLM/TREATING
Worken'Compenation laws of Gllfomb.Data PAID
Q Z Applicant NEW RESIDENTIAL FILMS. SQFI. Date Remi t#
Z Q NOTICE TO APPLICANT:1t,after making this Certllate o(Excmption,you
should become subject to the Workers'Compensation provbloru of the Lobar TOTAL:
�) Code,you mu at forthwith comply with each provisions or this permit shall be 13UILDING FEE
,UD
W > deemed revoked.
a G CONSTRUCTION LENDING AGENCY SEISMIC FEE
Ihdtha woekftr w there bacordtmction ssuAd(dAc,309nry .C.)or perform TOTAL: ELECTRIC FEE'
0 Z Leodn'thc work(car which this permit blwred(See 3097,CIv.C.) .UQ121, ob
V O Lenders No PLUMBING FEE
I- Iander's Address - QTY. MECHANICAL PERMIT FEE
LL MECHANICAL FEE
OW Ioerti(ythatlhave read lhbappBationand atatethat theabove Information
D. it comct.lag.to comply with all dtyand countyonllnames and nate lawn I•ERMRISSUANCE J„ FEES PAID-
>.
AID
} relating to building construction,and hereby authorize representatives of this
h N city to enter upon the above-mentioned property for Inspection putoners. ALTERORADDTOMDZIL L70
Z (We)agree to save,indemnify an d keep harmless the City of Cu Perrino Date Receipt#
O agairu ics,judgments,mgrand expenses Ich may In any wayacdue AIR HANDLING UNIT(TO 10,ODO CFM) SUBTOTAL: 6
rug tai ity in o(the nun lhlspermit. AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
'Sitilhatufm ofApBn/ nt
orador Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
ca
HAZARDOUS MATERIALS DISCLOSURE'
Will the applicant orfuturebuildingoaupant store or handle harardous HEATING UNIT(TO 100,000 BTU) Date RCCCI t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
HnIth ami Safety Cede Section 25532(.)7 HEATING UNIT(OVER 10),000 BTU) TOTAL:
❑Ycs No
Wflltheappliantor wmbulldNgo panluuequipmentordevires 1 VENTILATION (SINGLE RESID) ISSUANCEDATE
which eMthaaaent air rict? nis acue defined by the Bay Area Air 0
Quality Mag hnramt District? BOILER-COMP ptm OR 100,000 BTU)
4Yea ❑No
have read the aaamous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) C
the Calh
lfamla Health&Safety Code,Sed ions 75505,25533 and 25536.1 p/
understand that lithe building don not currently have a tenant,that Itis my NEW RESIDENTIAL MECH SQ.Ff. 1S5�x3T
mapomibillty to notify the occupant of the requirements which moat be met
prior to issuance of a Certificate of Occupancy.
0
Owner or authorlud agent Data � RUED BY:
TOTA4
OFFICE COPY