19550 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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Building Pro'e I Identification PLRMTNO.
:@ulldinsa13,95' /%Teor 0 cuerlou 19550
wners Phone:
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ars, " �a7 CITY OF CUPERTINO-BUILDING DIVISION — �� _� a
Cnntra1m'5Name: � //''__��JJ//-- Lic.No: APPLICATION /PERMIT l/
G EAR �A7FR AO Pd,6d Ze. Aoi 38506 BUILDINGELEC7WCALM' BINGMF HAMCAL CATEGORY CONTROL M
Architect/Engineer. Lk No:
� ) QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address 3 YQ/r (.(/ ,r.oaT CA Jr S PERMITISSUANCE ❑ ❑ ❑
LICENSF.DCONTBA OR'SDECLARATION
I herebyaffirmthm l am lkensed under providonaof Chapteri)(commenc APPLIANCES READENTIAL JOB DESCRIPTIONIngwlth Seaton 7000)of Dlvisim3oftheBusinemand Prof sslons Cade,and my
license Isla full force and d(ect. PANES
Licenserr1 I `Licensenu Clam Cont // V-L-
Date Contractw^or
ARCHITECPS DECLARATION 2014000AMPS
1Q+�re CTO I understand my plans shall be used m public records. OVER 1000 AMPS SQ.IT.FLOOR AREA f S/SQ.FT.
E () Licensed Professional SIGNS ELECTRICAL
< OWNER-BUILDER DECLARATION
fn °tot SPECIAL CIRCUIT/MISC
Thereby af0rnthat lamexempt fromthc Cont raaorb License Lawfo the
7Q_ following renters.(Section 70315,Business and Professions Code:Any city or TEP MEIN OR POLE INST.
OLr'� t
coun whichrc 1 ermittoconstmct,alter,Improve,demolish,orre
KE � qu resaP P Pair
any atsr uaurcprier Renshaw he Is lionedpunheappthe forsuch provisions
f the ppkyER DEVICES
file a signed statement that M V Ilansed pursuant to the provision m( the
3 + Contractor's License Law(Chapter9(mmmenang with Section 7000)of Divi- SWIMMING IDOL ELECTRICCj
1.,E05 sion3oflhe Business and Professlora Code)orthat he is exempt therefromand VALUATION
Q �.' the basis for the alleged exemption. Any violation of Section 7MILS by any OVILElSSW1TCITFSFIXTURES
❑ a pplicantforapermiteobjedstheappbcanttoadvilpevaltymfnam mthan
five hundred dollars(5500). NEW RFSIDFN77AI.ELEC7R SQFf.
Q ❑I,m owner of the property,or my employees with wages as their sole ^ STORIES TYPE CONS772UCTION
compensation,wllldo Me work and thestruaure I9 not Intended or offered for
❑ tole(Sec.7044,Business and Professions Code:The Contractors License Law l/
F{$g does not apply to an owner of property who Wilds or improves thereon,and OCC.GROUIP RFS.UMTS
EE who does such work himself or through his own employees,provided that such
Improvements are not Intended oroffered formic.If,however,thebuliding or TOTAL:
Improvement bsold withinoneyearofcompldion,the owner-builderwill have
IhAmden of proving that he did not build or improve for purpose of ole.). QTY, PLUMBING PERMIT FEE FLOOD TONE APN
u L as owner of the property,am emIusively=trading with licensed
peopect contactors to canslrud thePretenders, PERMIT ISSUMCE(Sec.7044,Business and PretemloCode: a-0 0
The Contractor's License Law does net apply to an owner of property who ALTER-DRAIN&VENT WATER(EA)
builds or Improves thereon, and who contracts for such pRojects with a
cq➢lfactor(s)Bcensed pursuant to the Centimeter.License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
�I I am exempt under Set. B &P C for this mason
OUTSH
DRAINS FLOOR ROOF,AREA,COND. SANITARY V_ N_
Owner Date RECEIVE M
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y_ N_
❑1 hereby affirm that I have a certificate of cement m self-insure,ora RECEIPT M
certificate of Workers Compensation Insurance or a unified copy themof(See. GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y
3800,Lab C.) — N
NM
IpulleyR
8 ViaCAS EA.SYSTEM-OVER 4(F.A)
Com any BUILDING DI VISION Fin ES
certified copy b hereby furnished. CREASE/INDUML WASTE INTERCEPTOR PLANCHECK FEE
Certified copy ie filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANRARY-STORM EA.20017. Date Recei t#
(rhlssectimn need net be completed tithe permit b forma¢hundred dollars
(510 mirtless.) WATER HEATER W/VENT/ELECTR OD ENERGY FEE Y N
I anloas.) otthe pedormanaof thewokforwMch this permit is issued,
I shall not employ any person In any manner su as ro become subject to the WATER SYSTEM/TREATING
Workers Compensation Laws of California. Date PAID
O Z Appllunt NEW RESIDENTIALI LMB. QFT. Date Recei H
Z O NDTICETOMPLICANT.1f,. ermakingthb Cenlflateof Ex e=.,you
should honors,subject to the Workers'Compensation provisions of the Labor TOTAL:
IX N Code,you must forthwith comply with such provisions orthls permit shall he BUILDING FEE
W > devoted revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Z Ihumbyaffirm that there is a construction lending agency for the perform- TOTAL: p0 ELECTRIC FEE
7 anceuftheworkferwhichthb Nrmitb Wud(Sec.3097,Civ.C.)
02
Leoder.N.me PLUMBING FEE TOO
LL f Lcedcr's Address QTY. MECHANICAL PERMIT FEE
O w Icertifythat l have read this application and statethatthe above Information MECHANICAL FEE
1 iscoma.Iagre tocomplywlthalldtyandcountyordinanmssandstatelaws PERMIT ISSUANCE FEES PAID:
>_ 0. to building com uction,and hereby authaare representatives ofthb
H N city to enter upon the above-mentioned property,for Inspection purposes. ALTERORADDTOMECH.
Z (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
V agaWtliabilities,judgment,costs and experuses which may Inany way amme AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL:
egainst.ald itymc...equen ( thi.permit/ /�
�'I �k AIR HANDLING UNIT(OVER I0,000CFM) CONSTRUCTION TAX
13
sew eFeo Appliart/Contractor /Dam f EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a ppllam orhmm building occupant store or ha rd le hazardous HEATING UNIT(TO 100,0M BTU) Date Recel tN
materbl as cleared by the Cupertino Municipal Code,Chapter 9.12,and the
Ilallhand Safety Cede Section25532(a)? HEATING UNIT(OVER 100,"BTU) TOTAL: t11
❑ Yes MN.
Willtheapplicant orfatureindliingoavpant useequlpmentordevices VENTILATION FAN(SINGLE RESID) ISSUANCE-DATE
which emit harardom air contaminants as defined by the Bay Area Air
.
Quality Management District? BOILER-COMP CHP OR IW,0M BTU) a
Ycs o
have read theM1aza9.0materials requirementsunder CM1apter 6.94 of BOILER-COMP(OVEt 100,000 BTU)
the Cabfomla I Ialth&Safety Code,Sections 25505,25S33 and 75534. I
understand that if the building does not currently have a te...L that it h my NEW RESI DENTIAL MECH. SQ.Fr
responsibility to notify the occupant of the requirements which=at be met Clhf net rr)ngrtino
prior to o aCeniftoo an
nermauthorired ail t f Data I ISSUEDBY: V
TOTAL:
OFFICE COPY