19943 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulidln Pra e<t Identifintion PERMITNO.
BuOdhg Addmss: Q ; I V J-5 rsd 19943
nerd ame: Phone:
aQ�LJ t•�• V ,25,Lo 6fr CITY OF CUPERTINO-BUILDING DIVISION
onlradoYs Name: Lie.No: APPLICATION / PERMIT
+ Hti' BUILDING-ELECTRICAL PLUMBINGMFOHANICAL CATEGORY CONTROLN
Archimot/Enginmr. I No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address
PERhBTISSUANCE
N
TUME, MUCH
11IhyLICENSED CONTRACTOR'S DECLARATION �ElQ{/sw ie
❑ ^�
ON
NtlamlkmsedoW hapter9( mmm APILIANCESRESR7EN1AL
ingwthSfon7ODlvlelo3o(th.BudnmdProfexosCode,andm
IsInh0fnrccaand PANELS
LtcenseClan c.
Data., Conhactor
ARCHITECTS DECLARATION 701400OAMPS
q�q�uu X p ' I understand my plane shall be used as public remrdw OVER IOW AMPS SQ.FT.FLOOR AREA f/SQ.FT.
E Fj ,Licensed Professional SIGNSELECTRICAL
]6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MLSC
-Z H,iA 7a 1herebyaflmetlat lam exempt froenthe Contadoes License Law for the
following reason.(Section 70315,Busher and Professlo..Code:My city or
'O H TEMP.METER ORIOLE INS[.
countywhich requlreeapermit tommtrod,alter, demn0sh,arrepilr
anystmc mpdortoitalawamc alsorequre theappliantforsuchpemdtto POWER DEVICES
O file a signed statement that he is licensed pursuant to the provisiom of the
�rt Contractors Lic...Gw(Chapter9(mmmencing with Section 7000)of Divi- SWMWNG IDOL ELECTRIC
e1on3ofthe Budnemend Pmfewtom Code)orthatheke.emptlherefromand VALUATION
`�O the basis for the alleged exemption. Any violation of Section 7071.5 by any OUTLE7SSWITCHESHX'NRES
appllant fora permit subjectsthe applicant to a civil penalty of not morethan
live hundred dollars(g5 ).
1,as owner of the property, NEW RESIDENTIAL ELECTR SQFF. SIOWFS TYPECONSIRUCTION
7< ❑ p perry,or my employes with weeds r there wk
coIc T.Don,will B.ido the work,and the strudureh not Intended or catered for
�O cele lase 7046,Buvines.and Professbru Code:7he Contradofa Llceme[aw
does not apply to an owner of property who builds or improves therem,and
5^ whodoeseuchwmkhlmeelfm1hroughhisownemployeae,provldedthatsuch OCC.GROUP RIS.UNITS
Improvements are not Intended oroffered formic.I;however thebuliding or TOTAL:
Improvement lssold withlnaneycarofcompldt n,theowner-buiderwill have -
tl urdenof proving that he dld'na build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
tyae owner of the properly,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7094,Business and Professions Code: .LsH�
The Conenctorb License law does not apply to an owner of property who ALTER-DRAIN kVENT-WATER(&U
Wilds or Improve thereon,and who mntam (a such pVjem with a FEE SUMMARY
�qB(�+cieer.r(s)licensed pursuant to the Cmtradoe.License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under SB k P C for this reason
nuTsInFFEES
Owner Data
DRAINS FLOOR{ROOF,ARRA,GOND. SANITARY Y N
RECEIPT N
WORK MAN COMPLNSATION DECLARATION FDnURES PER TRAP SCHOOL TAX Y N
❑I hereby affirm that I have o Issuate of consent to oself-mourspytherco ora RECEIPT N
3800ricate Lab Cf Worken'Compematlen lraurance ora certified mpythemof(Sec. GAS.EA.SYSVA-11NCAOUTLETS �(� PARK FEE Y N
1'ollry p GAS EA.SYSTEM OVER 4(Fit) DINGBBCDf N
om an
Cy BUILDING DI VISION FEES
❑CertlOed copy la hereby te city
❑Certified copy la(fled withh the cicity inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASE7RAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-SIORMEA.700FT. S� Date Recei t#
l0).H.bn need not bemmplded if the permit k fa one hundred dollars
(g}Icomless.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I cenet that In the performance of the mworkanner
so as to
lwe permit Is leo the
I shall not o y any perean Ipgny manner n m to berome misted to the WATER SYSTEM/TREATING PAID
Waplimu'o nsatlon (Calif la.Date
PP NEW RESIDENTIAL I'LMB._SQ.Ff.
Z Q NOTIC ntO A ,ager making thk Certl(late of Exemption,you Date ReeEl t#
Fshouldcre subject to the Worker'Compematlon provisions of the Labor r(� �3 �D TOTAL:
CC y Code,ya mustforthwith comply withsuch provkhm."his perenit.hall be f �V 'pvA eZ
FEE
W j doomed revoked. _ G
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a I herebyaa0rmthat there is a construction lending agency for the perform ELECTRIC FEE
7 Z antt of the work forwhlch this permit to Issued(Sec.3097,CIv.C.) TOTAL:
V O ' Lander'.Name PLUMBING FEE 21%co
LL h Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O WImrtlfythatlhavemadthisappllcatlonandetatethallheabovelnformatlon
kcorrect.Iagmetocomply with all cityandmumlyordlnancesanddalelaws PERMIT ISSUANCE FEE$PAID:
1
�. 0. relating to building construction,and hereby authorlem representatives ofthLs '
F inspection to enter upon the above-mentioned property fee pection purposes. I ALTER OR ADDTO MICH.
U) veDate ReCCI t#
z (We)agree to saw,Indemnify an d keep harmless the City of Cupertino
against liabNties,judgments,cormand expenses which may In anywayamue AIR HANDLING UNIT CrO 10,000 CFM) SUBTOTAL:
against mid City In consequence of the granting of this permit.
ATR HANDLING UNIT(OVER 10,000CFM) . CONSTRUCTION TAX
SlgmWre of AppBmnt/Contractor Date WtAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applitorfuture building occupant store or handle hazardous HEATING UNIT(TO IW,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 933 and the Date Recei t#
I lealth and Safety Code Section 25537(a)7 HEATING UNIT(OVER IW,OW BTI TOTAL: a
❑Yee No
Will the applkard or tum W lLdingorcvpart use equipment or devices VFNILATION FAN(SINGLE RE-%D) ISSUANCE DATE
which emit hazardous alrcontaminacam defined by the Bay Area At, ' ) 199�U
Quality Management District? BOILER-COMPpW'OR 1fX{IXU BTU) I t 11• i+ (+ 1
Ye No
Have read the hma ossamaterial.requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) k,
theersta ndt HealthkSafetyildin Code,Sectiomntly have
a tend,that34.
the California [Health
Wilding does not tions2lyh,25533 and 2SSat ltlamy NEW RESIDENTIAL MECH. SQ.FT
rnponibil mnotllylheoc aotofthe menbwhlchrnustbemet
prlorlol anceofa Cecil eof -
or authorized agent Date - ISSUED BYtI���'V•
TOTAL:
OFFICE COPY