19833 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PERMIT NO.
Building Address: 1
M; . °d - L1p��� c 19833
3nav ams: �wr YTS— •5� _ O IT•- A
0k"_ U KO CITY OF CUPERTINO�BUILDINGDIVISION
CdoiaName: I Lk.Na APPLICATION 1 PERMIT 3 —�— /
lra
5 / ✓Ix Ic? /' CATEGORY CONTROL#OW J
Aro / Rlneer. Lic.Na BUILDINGELECIRICAUI'LIIMBINGMGCHAMCAL
It w ba <./ BUILDING PERMIT INFO
QTY ELECTRICPERMIT FEE �/�
Address 6 N S,yaiil-A C �'i1 ✓7� PERMITISSUANCE .DO y[
LICENSED CONTRACTOR'S DECLARATION /+•+
I hereby affirm that l am licensed under provWonso(Chapter9(commenc APPLIANCES-RESIDENTIAL JOB DESCRIPTIONIngwlth Sedlon7000).(DiWWm3o(the Butlnessand Pmfe onsCode,andmy
License
Is In full and effect. PANELS
Lirens
DueClass Lk.# S
Date Contractor IF/1
ARCHITECTS DECLARATION 701-1000 AMPS
pQ+m Z I undenland my plans slug be used as public records. OVER 1000 AMPS SQ.Fr.FLOOR AREA $/SQ.Fr.
E� Licensed Professional SIGNSELECTRICAL L Q� 3, 7U ter/
«<<�' - OWNER-BUILDER DECLARATION 1 / L
F.rrr/wvj FFF�AAd 1herebya(flrmthm st I aexempt from the Contractor's License law f¢the SP[CfpLCBtCUIT/MISC
Zp p following reason.fSedion 70115,Business and Professions Code:Any city or
TEMP.METEROR POLE INST.
county which Priorwrequi .sBastions,alsore requires
esthlter, Aprove,demsuch,erentto 7/ _ I�
4q� anystructuretatemeitthateIs Bastions,also rcrsue.,to I.t(¢.uc.rd of t e POWER DEVICES ( o
�+ (Ile a signed statement that he ie licensed punuanl to the provlalom of the
3w Contractor's License Law(Chapter 9(commanding with Section 7000)of Divi. SWIMMING BOOL ELECTRIC ON
VALUATI
�0 elon3oflho Rusbessand Professlor C.de)orthatheleexempttherefromand
the Weis for the alleged exemption. Any violation of Section 70315 by any ' O y"7� , I
0 applicant for•permit subjects the applicant to a dAl penalty of not m.rc than OU71,ETSSW1TCHESiFIXTUR "
Oc undrcd dollars(5500). NEW Rp..Ic ppMlpL Et-p.CTR y7pWF5 TYPE CONSTRUCTION
�n I,as owner.(the property,or my employees with wages as their sob
< c pensati.n,wdl clothe work andthevtructure b not intended or offered for D•�
❑ o fSec.7064,Buab ox and Pm(nelons Code:The Contractor'.LI¢rue Law
$ does notapplyto an ownero(property,who Wilda or)mprove.thereon,and OCC.GROUP RES.UNITS
who doessuch work himaeff orthrough his own employees,provided that such
improvemants are not intended oro(fered forsale.If,however,the Wilding or TOTAL:
Improvement issotdwlthln oneyearofcomp:eiontheownenbullderwill have
tyI"-•�)'rden of proving that he did out Wild or Improve for purpose of sale.. QTY, PLUMBING PERMIT PEE FLOOD7DNE APN
as owner of the property,am exclusively nontrading with licensed ppD ISSUANCE - p
N
he project(Sec.7044,Business and ProfessionsCds:e I�w don na apply to an owner of property whoALTER-DItA1N&VENT-WATER(EA)xon,and who nm for such poje s with amrant of s LlconseLaw. BACI(p[AW pROTpGT.DEVICEFEE SUMMARY
er B&P C(or bre nOUTSIDE FEES
DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y N Date RECEIPT#
N COMPENSATION DECLARA 1 N p ps�TRAP SCHOOLTAX Y_ N
❑I hereby affirm that I have•certificate of...or to self-Insure,¢a
``I certificate ofWorkeri Compnuatlonlruuran¢ora¢rtifled ropy lhere.((Sec. PARK FEE YFLEQ'T#
If 3B00,Lab C.) GAS EA.SYSTEM-1 INC.4 OUTLErS
policy p - GAS FA.SYSTEM-OVER 4(PA) RECEIPT«
Cam Ccny BUILDING DIVISION FEES
1 I Certified copy is hereby famished. CREASE/INDUSML'WASTE INTERCEPTOR PLANCHECK FEE
CertRied copy l.(Iled with the city Inspection divl.lon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE7RAP PAID
COMPENSATION INSURANCE SEWER.SANITARY-5NRM EA 2(pFl. Dale Recei tp
(1),asectian need not be completed lithe permit b(.none hundred dollen
(f100)nify that
WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Icertl(y lM1at tithe perfemun¢olthework I.,which lM.penNllvbwN, •,
I shall n¢employ any person b any manner as,as to become subject to the WATER SYSTEM/TREATING
Works/Compensation Laws of California.Date PAID-3'"O
O Z Applicant Date
Recei t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
NEW RESIDENTIAL PLMH. SQ.I•T.
Should become subject to the Worken Compemat ion provisions of the Labor TOTAL:
CC W Code,you must forthwith comply withsuch proviabmorthis parmshall be
Of
W > deemed invoked. - - '
EE IX G CONSTRUCTION LENDING AGENCY SEISMIC FEE .s,9/a7
a Ihereby 4fflmC0htthem baconstrudlonlendingagenryfortheperform ELECTRIC FEE ,y
Z an.of the work for which thin permit is issued(Sec.3097,Civ.C.) TOTAL: p'
V O Lmdeia Name PLUMBING FEE
IL I— Lender'.Add ass QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW 1comlythat l have read thbapplicatbn and aatethat the ab.velnformation
1 bno agreetocomplywkhWAtyand nountyordbanmand nate laws PERMIT ISSUANCE ,� PEES PAID:
rets gto Ildingnomtructory and herebyauthorizerepresentativesofthls
(— Z
cit to ante upon the abovcmentbned property for inspection purposes. ALTIX OR ADD'11�MECH. Date ReCef IM
(We)a a to rave,indemnify an d keep hsnNesa the City of Cupertino P
V a ainetR illi marts,costsand expensnwhich may b anywayaccrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL' Im
a but Id t of Is pAn ermit AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Xg o Ap li o a m E%HAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID: -
HAZARDOUS MATERIALS DISCLO URE _
Will the applicant or fu me building occupant store or handle hazardous MATING UNIT(TO 100,000 BTU) Dale Recei t(f
rtuterial as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I and Safety Code Section 25S37(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes ri No
Wiillheappli¢ntorfw mWildbgoceupanluwequipmentordevida VENTILATION FAN(SINGLE RFSID) ISSUAN ATE
�h emit Wzardoua ab contaminants as defined by the Bay Area Air p/�
}y Marugement DisMct7 BOILER-COMP OHP OR 100,000 BTU) P�41
(Yea ❑No
'Cue, read the hazardous materlala requirements under Chapter 6.95.( BOILER-COMP(OVER 100,000 BTU) JUN 281990
1, Ir a Califomiabfeakh&Safety Code,Sectioru25505,25533 and 75536.1
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECA. SQ.FT
responsibility to notifythe occupant of the requimments which must be mel �V u65aI
prior to Issuance of a Certificate of Omtpancy. Pit1sII
. - ass
Owner or authorized agent Data ISSUED gy; 0Ir V
TOTAL:
OFFICE COPY