20876 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
building project IdentificationPERMIT NO.
Building Address: tO '/0 7 C
.100 ti fr a c Je lkin P,d , G I U
r¢ra one: A AL DAIL
'•p�,p y CITY OF CUPBRTIN46UILDING DIVISION 0
cemra�r.wn . �-• =` — L1c.No: APPLICATION / PERMIT
0-4 RUIMINGELECIRICALPLIMBINGMTLHAN'ICAL CATEGORY CONTROL N / 7�
4 AnN�uett/E��ngiTneer Lle No: ((
/y�� Lp}1' ' �T,� 4 QrY : ELECTRIC PERMIT - FEE` • : BUILDING PERMIT INFCIJ,;', -•.
Addresa� S,I f rK ' .: '/AJ51J. S PERMITIS5UANCE D D D
LICENSED CONTRACTOR'S DECLARATION
I hereby dfirm that l am licensed under provblonaof Chapter 9(d,.c- APPIIANCESRES7DENTIAL
ingwith Sec .7000)ofD,NMon3aftheBusinessand PmfeadonsCode,and my
hodue Is in fullforce and effect. PANES � /
Livae Class LIC �
K / �� U 4`!-
Date Contractor UP TO 2DO AhQS
ARCHITE SDECLARATION 201.1000AMf5
TOL 7uny[N�and,., uraly blic records. OVER1000AMPS SQ.FT.FLODR AREA S/SQ.FT.
j C L //II�•__✓c+feraraI o /" ( � SIGNS ELECTRICAL
dwfeA OWNER-BUILDER DECLARATION
<jB SPECIALCEtCU17/M15C
I herebyaffirm that I am exempt from the Contractor's License Taw for the
)_� following Mason.(Section 70315,Business and Professions Code:Any city or TEMP.METER OR POLE INST.
.p county which requirma permit tomrutruct,alter,Improve,demolish,orcepalr
arystrucum pri its Issuance,alsorequiresthe applicant for uch permit to POWER DEVICES
C< file a signed statement that he Is Bxm naed pursuant to the pro,bioof the
Contractor's License Law(Cha pter9(commencing with Section 7000)of Divi-
SWIMMING POOL ELECTRIC VALUATIO
'O dien3of Ne Budnessand ProfnaiomCode)orthathetsexe�ipttherefmmand �U
Sn S the bas's for the alleged exemption. Any violation of Section 70315 by any OUTLET SWITCHES FIXTURES Z 'R-6
applicant for a permit mbjectsthe applicant to a civil penalty of not more than
,$ five hundred dollars(SM. NEW RESIDENTIAL ELECTR SQJT STORIES TYPE CONSTRUCTION
❑I,as ewar of the property,or my employees with wages as their sole
.7 compensation,will do the work and the structure b net Intended or offered for
Osale(Sec 7064,Busbies,and Professions Code:The Contractors License Taw
:$$ don not apply to an owner of property who Wilda orimpmveseR
theme +nal OCA.GROUP RES.UNITS
who don such work himself orthrough hisown employees,provided that such
Mpmvements arena intended oroffered forsate.IL however thebuilding or TOTAL:
impmvement bsold w hinoneyearofcompldiogtheewner-WBderwill have
tFajZa rden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING,PERMITq•" .`FEE"' FLOOD ZONE APN
"L as owner of the property,am exclusively contracting with Bernard PERMITISSUANCE
contractors to construct the project(Sec 7014,Business and Professions Code:
Tim Contractor'.License Law does not apply to so..at of property who ALTER-DRAIN&VENT-WATER(FTU _
Wilds or Improver thereon, and who contracts fee such pmojects with a .,)
cgWT�ctor(A licensed pursuant to the Contractor's License Law. }F'r. FEE SUMMARY:- .j.•p
LJ I am exempt under Sec B&P C for this reason BACK FLOW PROTECT.DEVICE -
ASANIDRAINSFLOORROOF,AREA,COND.
TARY Y N
Owner Dde RFCEBT 0
WORKMAN COMPENSATION DECLARATION SPER'IRAP SCHOOL TAX Y_ N
Cpl ❑I hereby affirm that I have a certificate of consent to self-Insure,ora FEKTURERECEIPT N
-" certifi.m.Workers Comperation Insurance ora¢rtified copy thereof(Sec. GAS FA SYSTEM-1 BNC.4 OUTLETS PARK FEE Y N
3800,Lab C.) RECERrT N
�mryz GAS EA.SYSTEM-0VER 4(EA) BUILDING DIVISION FEES
ertBiad copy ts hereby tomit al, GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WO R K ERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-MRM EA ZOOFT Date Recei t#
CTMs section need not be completed lithe permit b fm or hundred dollars
(s100)or les.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
1 certify Nato the performance n the work an as to Become
penult is to
the
I shag not employ any person In any manner w u to became subject to theWATER SYSTEM/.TREATING
Workers Compensation Lss of CaRfomu.Date PAID
1 Z Applicant Date Remi t#
NOTICE TO APPLICANT.It,order making flus Certificate of Exemption,You NEV RESIDENTIAL PCMB. SQFT.
0 should become subject to the Workers'Compensation provisions of the Labor TOTAL:
' N Code,you resat forthwith comply with such proviaions or this permit shall Be BUILDING Z •0
I Gmdeeed oked. SEISMIC FEE
roCONSTRUCTION LENDING AGENCY
I hereby affirm that there Is a mmiruction lending agency for the perform, TOTAL: ELECTRIC FEE
Z and,of the work for which this permit is usued(Sce.3097,Civ.C.) PLUMBING FEE
O Lender's Name
r Lendce.Addrcs QTY. ' MECHANICAL PERMIT •'FEE MECHANICALFEE
• U I cert By that l have mad this application and date that the above Information FEES PAID:
W bcormect.I dgme to comply with all dry and county ordinames and date laws PERMIT ISSUANCE
d relating to building construction,and hereby authorize representatives of this
N cit to entero the above_mentioned forW Inspection purposes. ALTERORADDTOMECH.
Z Y poo lump
R Pf Co Dale Receipt#
(We)agree to save,LWemNfy an d krep harmlen the Clry of Cupertino
)
against liablBtiea,Judgments,cods and expenses which may many way acorue MR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL-
.g.inst said City in mnsryu ance of the granting ofthe.permit. CONSTRUCTION TAX
AW-RANDLING INTI(OVER 10,000 CFM)
Sigam ne of Applicant/Contractor Date EXHAUST HOOD(W/DI1CT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE TiFATiNC UMTCI'O IDO,000 BTU)
Will the applicant or future building occupant store or handle hazardous Date ReceI t#
material as defined by the Cupertino Municipal Code,Chapter 9.1;and the
Healthand Safety Cott Section 25533(.)} HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes ho
Will the apPB.m., no building oau pant uee equi pment or d evices VENTILATION FAN(SINGLE REBID) �$�IQ�E DATE
which emit havrdous air contaminants as defined by the Bay Area Air ���$$
Quality Management Disn Yes trict? BOILER-COMP OtB'OR 100,011)BTU)
1 Ihave read the F 7cuaomaterials requirements under Chapter 6.95 of BOMER-COMP(OVER l00,0W BM fl
the Califomia Health&Sifety Codc_%ctioo Z5505,5S33 and 25534. T
understand that if the building does not currently have a tenant,that It is my NEWRFSIDFNTIALMECH. SQ.rr
n
responsibilityto notify the occupant of the requirements which must be met f`'N �GI{• _._�
prior to issuance ola Cenifiate ofOavpanry. WsL ,.�
Owner or authorized agent Data TOTAL. ISSUED RY:_
OFFICE COPY