23678 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification PERMITNO.
eaI n3� � 23678
Name: _ one: p A
�7—d 7 CITY OF CUPERTINO-BUILDING DIVISION /� /lzj G
ca a r.Na Lie.No
�0 ! APPLICATION / PERMIT
�JJ BUILDING-ELECTRICA4PLUMBINGMECI IANICAL CATEGORY CONTROL N
Amhitect/Engtseer. 67Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PFRMITISSUANCE ❑ ❑ n ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby aff(vnthm lamlicensed hcunder Busiessa.d provisions ofCha pter9(rommena APPEANCESRFSIDENITAL JOB DESCRIPTION
Ing whh Section 7000)of Dlvimon 3 o(the Budnessand Pro(esslonsCrade,and rtry
Bcens lslnfu force and Lie.
,� PANELS
Date Class.= LION .7 5 nil AL 0,r
Date Contractor � t� �lr p/v/�LGA
ARCHITECPS DECLARATION 201-10WAMPS
0Z I understand my plane shall be used as public recordw OVER 1000 AMPS X).FC.FLOOR AREA S/SQ.IT.
CO
d 6 Licensed Professional SIGNSELECTRICAL
<w OWNER-BUILDER DECLARATION
Fn SPECIAL CIItCU1T/MLSC
I"' � Thereby affimnthatlam exempt(romthe Contractorb Lkxns Law(m the
MAO F^ following reason.(Section 7031.5,Business and Profemions Code:Any cityor TEMP.METER OR POLE INST.
countywhich requires a permit to construct,alter,Improve,derrolbh,orropair
�pe'� p
6 -I anystrudune prlorto its lwrance,atse,requirestheapplicant for such pemurto POWER DEVICES , ' I ,
EE m CGil file a signed statement that he Ls licensed pursuant to the pmvialom of the
�a Contractors License Law(Chapter 9(commencingwith Section 70M)ofDivi- SWA4MNGXJOLELECTRIC /t AT ON
�E, skm3 of the Business and Professions Code)orthat he 6 exempt thcmfromand
g .$d the basis for the alleged exemption. Any violation of Section 70315 by any TE
five
applicant fora permit subjects the applicant to a dvil penalty of not more than
p.,g OQ five hundred delta.($500). NEW RESIDENTIAL ELECIR FT.
O R� n 1,as owner of the property,or my employees with wages as then sole �' 'E CONSTRUCTION
(Sec.7044.
Buldrea and kandions Codurehecomended Licensed w
$�❑ sale(Sec.7044,Business and Ihvfenlone Code:The Contractote License Law
11,1 does not apply to an owner of pmpertywho Wilds orimproves thereon,and OCC.CROUP RFS.UNITS
GG who dmssuch workhlmrelf mthnvgh his..employees,provided that such
improvement are am Intended oroffered forsale.If,however,the W Ilding or TOTAL
improvement issold withinoneyearofcompidw
lan,the oner-builderwlli have
t!(�fvrden of proving that he did not build or Improve for purpose of sale). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
Lf L as owner of the property,am exclusivelycontracting with licensed PERMIT ISSUANCE —Q
contractors to cowtud the project(Sm.70K Business and Professions Code: 7, �
The Contrames License Law don not apply to an owner of property who
Wilds or Improvm thereon, and who comrade for such Imojects with a ALTER-DRAIN&VEM-WAIIIt(EA)
�q➢I ador(sl Bcenscd punuanura the Contractor's License Law. BACK FLAW PROTECTDEVICE FEE SUMMARY
LJ I am exempt under Sec B k P C for this reason BACK OUTSIDE "
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
Owner Date RECEE 1`N
WOR"AN COMPENSATION DECLARATION FIXTURES-PER TRAP SCHOOL TAX Y_ N_
aL-.- l hereby affirm that I have a certificate of consent to self-insure,or a RECEIPT N
nAfteateof Workeea Compeneatlonlneurance mamdlflM copytheroof(Sec. GAS EA.SYSTEM-1 INCAOULEIS PARK I•l:E Y_ N_
3800,lois CJ - RECEQ'TN
PolfsyY '- GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
On
�CertNe copy.sf'Ler famished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
-[71 Cert1(ied ropyb(iMd with the dty lvpectlon division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASETRAP PAID
COMPENSATION INSURANCE
(TSEWER-SANITARY-STORM EA 200Ff Date RCCCI (#
his on sectineed nd be completed if the permit isforone hundred dollar n
($10(fimle..) WATERHEATER W/VENT/ELECTR Snw ENERGY FEE Y_ N_
I certifythat in the performance of the work for which this permit Is Issued,I shall not employ any person in any manner w as to become subject to the WATER SYSTE4/17MATING
Workers Compensation Laws of California. Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FI'. Date Recei t#
Z O NOTICETO APPLICANT.If,aNer makingthb Centillcaleof Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
W Cade,you must fort hwith comply with surh provisions or this permit shall be BUILDING FEE
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d I berebyalflrtnthat there isaconelfadion lendingagency forthe perforrry TOTAL: ELECTRICFEE
D Z once of the work for which this permit is issued(See.3097,Civ.C.)� O lander'.Name ,
(_)LL H Lenders Addrcm QTY. MECHANICAL PERMIT PGE PLUMBING FEE
MECHANICAL FEE
O W I cedilythatl have madthisapplicatlonand statethattheaboveinformation
4 acoingtobagree lo comply with all ndhembyuuntyordmpressand datelaw. PERMIT ISSUANCE FEES P/JI Q..__
} relating to entruponge aWvc loganddpropetyor hercctim,prposs.thio -®/—�Ly�
Z city to )arectosaeabovcnallyaned property Wpe Cit purpose. ALTER OR ADDTOMECH.
(We)agree to save,Indemnify an d keep harmiem the City of Cupertino Date Receipt#
V against liabilities,judgments,costsand expenses which may In anyway accrue AIR HANDLING UNIT(TO 10,OOOCFM) SUBTOTAL:
against said City in consequenceof the granting of this permit.
AIR FIANDENG UMI'(OVFR]O,WOCFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUS'THOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haaardous HEATING UNIT(TO 100,0D)BTU) Date Reuel t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
I lealth and Safety Code Section 25532(a)I HEATING UNIT(OVER 100,000 BTU) TOTAL:
Dyes No
Will the applicant uFluium building rampant use,equipment or devices VENTILATION FAN(SINGLE RFSID) IS�.SaUdA�NftDATE
which emit ham Ideas air contaminants as defined by the Bay Area Air
Quality Management District? IIOTLER-COMP(31111 DR 1 00,0W BTU)
Y_a No
have read the h m materials requirement under Chapter 6.95 of BOILER-COMP(OVER IDQ(X0 BTU) JUN 18 199
the GIIlornia health A Safety Cade,Sections 25505,25533 antl 2x534.I
understand that lithe Wlldingdms rat currently haveatenant,that ltismy NEW RESIDENTIAL MECH. fQ.FT
responsibility to notify the occupant of the requirements which must be met �s
p' r to Issuance of aCeAtlI to Occupancy.
'VITT VY �NIJIaGT1111VV
Your or authodud agent Date Tornl: ISSUED BY:
OFFICE COPY