20804 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'en Identification 7 PFILMET NO.
Bu Odirz Adddmv;:: C;�' C c �-s �•f / .� �q-rte_`� n O O O A
G o 4
one: APPLICA I LUN bUUMI I I p
Rpt 1 17a45A(�� ,7Sy�yCIr CITY OF CUPERTINO-BUILDINGDIVISION
Contaadnla Name. Lic.Nn: APPLICATION / PERMIT
GIdSSIC._ K'I I`-iSX.�1.15 • S9-7SL2 BUILDINGELECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROLN
Amlifted/Engineer. Llc.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address IL3 q- S. SA%pWZM St/Pll`I"(WICK ILo• PERMITISSUANCE Cb
LICENSED CONTRACTOR'S DECLARATION
I hereby afffrmthat lam lfcensedunder pcovelonsof Chapser 9(comman, AI' MANCESRESIDENIIAL JOB DFSCRIPIION
Ingwith Section 7000)of Dlvision3ofthe Busines+and ProfnsionsCode,and my
license is In fou fprceand effect. .L PANELS
License Class 1S`I LIc.I S4'l SZ'
D.c-7jzqq0 not. or �;00-utA' WI y UP TO 200 AM15
pi
ARCHITECT'S DECLARATION 201-1000 AMPS
.7I understand my plans shall be used as public records OVER1000AMPS SQ.FT.POOR AREA $/e.Q.FT.
() Licensed Professional SIGNS ELECTRICAL
<m OWNER-BUILDER DECLARATION
SI'ECWLCIRCUIT/MISC
Ihercby affirm that lam exemptfromctb
the ContmoLlrense Law for the
77 2. following reason.fSectlon 7031.5,Business and Professions Code:Any city or TEMP. OR POLE INSAT k
r^� county which requires a permit to construct,alter,impmm
ve,deolbh,or repair
,py any structure prior to its biwance,also requires the a ppllcanl for such permit to i-0WFR CFS
0 file a signed statement that he b licensed pursuant to the provision of the
X0.0.0.0.5 O w Contractors License Taw(Chapter 9(commencing with Section 7000)of Diet.
F�Oa slon3otthellnessand Pro lmo Code)ordat hebexampltherefromand SWIM'WN TELE VALUATION
yl.. the basis for the alleged exemption. Any violation of Section 7011.5 byany OUTLETS-SWI ES
<i applicant for a permit subjects the applicant to a civil penalty of not mom= 1
c. five hundred dollars(SM. NEW RFS[D L TR
❑I,as owner of the ro STORIES TITECONSIRUCTION
p perry,or my employes with wages r ffelr sok
�7 Q com(Sec.7 on,will BusinctW w rl,,andProles thesions Code:
e is The Contractors Inteno icense dfor
Law
p sale does nota ply Bu siness and Professions Code:The ilds orimproveLenton law
g whorl isuch torn owner ofproperty
rough who nempor(mprwated that such
nes^ whodoeasuchwork hlrnself or through his ownemployees,providedthatsuch ,,te.�nr� OCC.GROI/l' RIS.I1NIl'S
improvements amnotimended oroffered for sale.ILhowever,Ihebuildfngor TOTAL: I W
improvementusoldwithinoneyearofcwnple Wmtheowner-builderwill have
lla.pudlcn of proving that he did nmbuudorimproveforpurpnuefwle.). QTY. PLUMBING PE MIT FEE
FLOOD 7DNE APN
"L as owner of the property,am exclusively contracting with nsed
)ice
contractors to constructthe project(Sm 70K Business and Profesiaru Code: PERMIT ISSUANCE
The Contractor's License law does net apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) l
Wilds or Imp.thereon,and who contracts for such p�oje is with a
cgpt[+ctor(s)licensed pursuant to the Contractor's License Law. BACK,FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B k P C for thin manes
OUTS I DE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
Owner Date RECEIPTX
WORK MAN I have COMPENSATION DECLARATION FIX.IURES PER TRAP "1 $C�IOOL TA% Y_ N
❑1 hereby affirm that I have a certificate of consent to u141nwre,or 4 RECEIPT Y
mrti0cate ofWorkers'Compensation lost:oiinnce or a certlflad copy thereof(See. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
MOO LabQRECEIPT X
GAS FA.SYSf7T1-0VER d(EA)
Com any 1a11C BUILDING DIVISION FEES
ffCeMRed copy is hereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECIC FEE
a czofed copy is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.20017. Date Recel t#
(This section need net be completed lithe permit Is forone hundred dollars
(SI00)orless3 wATFR ISFATFx w/vENT/p,FLTR ENERGY FEE Y_ N
I certifythat In the performance of thework forwhlch this permit is Issued,
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workeni Compensation Laws of California.Date PAID
O Z Appliont NEW RESIDENTIAL PLMB. SQFI'. Date Repel t#
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should beconr subject to the Workers'Compensation provisions of the Labor TOTAL:
CC W Code you at forthwith comply with such provisions orth1.permit shall be BUILDING FE
deemed revoked.
CL CONSTRUCTION LENDING AGENCY SEISMIC PEE
11 Z Iherebya(Brtntluuhercbaconstnvmon lending agency for the perform TOTAL: 1(.t ELECTRIC
ante of the workforwhichthb permitlakved(Sec.3097,Civ.C.) ` a
U O Leselce,N.me PLUMBING FEE l.t�CO
1•= lender's Address QTY. MECHANICAL PERMIT
O W Irenify that[have readthb applimtlonand gatafhatthe above ln(omatlon MECHANICAL FEE
CL Itcorme.I agree to comply with all city and county ordinance and state laws PERMIT ISSUANCE 1 G�C7D FEES PAID:
>. UJ relating to building construction,and hereby authorize representatives of this
cit to enterupon the above-mentioned propertyfor ins ection ses. ALTERORADDTOMECH.
Z y hap WTo Date Receipt#
oWill
to save,Indemnify an d keep harmless the City of Cupertino
V ea,pdg Is,mate end expenses which may In any wayaccrue AIR IIANDENC UMT(TO 10,000 CFM) SUBTOTAL:
( often.(the granting of this permit. AER HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
90 CONSTRUCTION TAX PAID:
ppB m/ or Date IXHAUST HOOD(W/DUCT)H RDS MATERIALS DISCLOSURE
plicantorlut building occupant store or handle hazardous HEATINGUMT(TO100,000BM Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I lealth and Safety Cade Sc N. m2:532(.)7 HEATING UNIT(OVER 100,000 BM TOTAL: 3.a
❑Yea No
Will the applicant o�ture building occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) 2s(� ISSUANCE DATE
which emit haranlous air contaminants as defined by the Bay Area Air
Quality Ma wgermot Dist rinl BDILER-COMP DEEP OR IDi BTU)
Yea n No
T
hahazy pifo read the us rtuteciab requirementsunderaChapter G95 of BOILER-COMP(OVE2100,000BM 1't
the California Health OSafetyddity Code,Sections25505,haveatand2S9atit JUG. % 19Jt1
on that if the building don not arrently haveaMnanL that itkmy NEW RESIDFM1AL hfECIi. SQ.FT.
nopmodeli y to not lfy the occupant of the requlrcments which most be rod
prior to issuance of a Certificate of Occupancy.
may, fly of CURErtiRQ�
Owner or authorized.gem Date TOTAL: T—"ccx) ISSUEDBY:
OFFICE COPY