99100085APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY _^� % O 1? � SSCP
CITY OI'' CUPRRTINO BUILDING - ELECTRICAL PERMIT NO.
APPLICATION/PERMIT Pr.�.hwBn�,,.rT,on'v'rt iA'nru)N
BU11,I)l urvL NEW
lslory 50001
01e -AA -;,6 G Tlz� L,v .
�UHESS'
37'7 Sr/c��lf� A/
❑ Consultant Fces Paid by Applicant (Initial)
YPY. ELECTRIC PERMIT
I hcrehy arena mot I at he ... ed code,pen win:, of Chapter') (a+mille.cing
with Section ]IXNq of Division I of the 1poinesx and P.,fessions Cade, and any license is
in fall farce and elect
Licence C.b+ss S Lic.a K
h Z I undcolund illy plans shall he used as public Mons T /
OZ��
H F' W Licensed Pndisninnal
cc <
OWNER -BUILDER DECLARATION
i C Iy Q 1 hereby afftmt that I am exempt tram the Cosion, Code:
A y c haw for the
X O a V following reason. roupnn 7031.5. Business and Professions Cale: Any city or county
1x13 V whichitsissuance.
saffairs, a permit re a res [he, alley, improve. suchmulish, or repair ed s.mcmre
F't='OQ prior millcenseePrlrvmquihabevisions of for Co mnce toicensfile ae Law (Chapter
i } theheisliccnscdpuauam tome provisionsofme Conusinss License Ww(Chapterr
LLy�� (commencing with Scnion ]fXXp of Division Jof the Business and Pmfessione Crdq or
a a C that he is exempt therefrom and the basis for the alleged exemption. Any violation of
WS m Section 7031.5 by any applicant for a permit subjects the applicantto a civil penalty of
not mom in.. five hundred dollms (5500).
5.
O ❑1. an owner of the property. or my employees with wages as their sole compensation.
F will do the work and the suuchre is not intended or offered for %ale(See 7044, Business
W
3 ec and Professions Cale: The Contractor's License Law dues not apply to an owner of
property who builds or improves thereon, and who dors such work himcdf..r through
his Own employees, provided that such improvements are not intended or offered lin
sole. If, however, the building or improveram is sold within one year of contra,....., the
h IJ 'ilk IM1 burden Ilow lowing did not h IJ p lin put
pose sale.).
0 1, us owner al tl po,perrY an exclusively contrawfing, with 111caled .aemm u+
consirtact the J 't (,Sec. ]PWG Busilicss and Porriesooto Coo,:) the trannicuor., L.I.
se law area no, apply. I property who build' -1 improve' fl +' and QTY
who cool mels for such projects with a commilar s) Biased Puvnam it) the Commelor's
Lkeno, law. _
I am exempt under Ser. . B & P C far this mmmn
APPLIANCES - RESIDENTIAL
PANELS
OPTO 200 AMPS
SIGNS ELECTRICAL
SPECIALCIRCUITIVI SC.
TEMP. METER OR POLE INST.
POWER
Owner Date
WORKI:R:S COMI'ENSATION DECI.ARATION
I and
w illlinn under pemahy of perjury one of the Worker's
Cru
JIhave coat will a far
Section
ofConvent to
Labe silt insure for Worker's Compete
sation, as prm�iJd for by Scninn AW of me Inb..r Cede, for the performance of the
walk for which this permit is issuol.
I have and will mairld. Wedoex Compensation Insurance. as required by Section
310)..( the Irby Code. for the perfmmaoce ci the work for which this permit is inuod.
My Worker's Compensation Insurance carrier and Policy numher are:
Carver. Policy No.:
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
1'Ihls.wdon nerd not he crmpl.difla, pirma, is fromm hundred dnllars(5100)
or less.)
cenily that ln. r cotthea orkfnr which this phe W, is isxucA,lshall
not cntPlay any nnYlr+n bee ons sub' rat he WnrknN Coin v
nation (,awn :nlihanin, Dr
Applinim
NOT"II' . CANT': r ma g i ilical ' um, Yon about]
bcaone.whjw. m the Worl' : Contpensa.i a 'o
......a on c nr c, yon mux
forbwithmntply with s wit"asi....ns ort permit shad r elate) revoked
CONSTRUCTION LENDING AGENCY
I hereby affirm that here is a construction lending agency for the Performance of
rhe work for which Ibis permit its issued (Sec. 3097, Civ. C.)
Lenders Name
L.cnderc Admx,,
I reedy that I have read this application ani sm a den 'he above Infomamlon is
correct. 1 agree or comply with all city and county ordinances and state laws relating (• QTY
building construction, and hereby mmoriw representatives of this rilln emer upon the
above-mentioned property for inspection purposes.
(We) agree .o nave, indemnify and keep harmless the City of Cupertino -01
t
liabilities luagmenp. coop and expenses which may in any way accrue agai dCiIy
in c urectmence of the granting of this pe,mi,.
I(ALA ) MATE SDISI. Unu
will maPPlia+arm
or
building ap.m euro 1,211L haoo o.amulalul
ux d0l by mu calx+lin+ Muni.ip cads, Chapter 9.1 and the IIaJth in.l Safely
Calc, Scrtlon 25532(0)!
E] Vex No
1 Will the applicant or future building ewcupant am equipment or devices which
all limitations air cnmmninanu us defined by the Bay Area Air Quality Management
Du.rir.?
[3 Vex Fl No
1 have read the interactions materials requirements under Chapter 6.95 of the Cali-
fornia Ike Safety Crate, See to
25505. 25533 and 255]1.1 mickcaaf that if the
hail' Les or c IAdwBB care,ryy ��t. that it is my respnnsibilayV, aI the IVNnt
,a .........«..... ruwn elI/+—hal" e7rim to issuance ofe Cenil/can �r+f(kY'ulMtV .
IM
NEWRESIDE jLELft
Al -
v
S/SQ. FL
PERMITISSUANCE
BUILDING PERMIT INFO
BLDG EA ECT 1'L11M11 / MIS❑CII
IL—
FEE
JOB DESCRIPTION
RESIDENTIAL
❑SFDWL ❑ KI'I CI IEN REMODEL
EI ADDITION ❑ I'LuMBING IU.1,11,17
❑MUUI'I-UNIT [ISTRUCl'ORA],
MODIFICATION
❑INTERIOR [-I CHIMNEY REPMR
�.IIMMP/PROVEMENT E] SWIMMING POOLS
&4K H REMODEUREPAIR ❑DEMOLI'T'ION
❑ OTHER
FIXTURES -PER TRAP
GAS- EA. SYS TEM- I INC. G OUTLETS
OCC. GROUP
-
GA -CA. SYSTE -OVER4(EA)Y
GREASFIINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FluS
GREASETRAP
\
1
(ADDITION 0DEMOLITION
yp ❑FOODSERVICE
NEWRESIDE jLELft
Al -
al FT. FLOOR AREA
-
S/SQ. FL
PERMITISSUANCE
AL]VR-DRAIN & VENT -WATER (EA)
VAI.GAT10N
cc 0
STORK VIYPI CONSTRUCTION
BACK FLOW PROTECL. DEVICE
DRAINS- FLOOR. ROOF. AREA, C i D
FIXTURES -PER TRAP
GAS- EA. SYS TEM- I INC. G OUTLETS
OCC. GROUP
/ At
i
GA -CA. SYSTE -OVER4(EA)Y
GREASFIINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FluS
GREASETRAP
PLANCHECK FEE
SEWER -SANITARY- STORM EA, 21X11'(.
ENERGY FEE
WATER HEATER WIVEN"1II?LFC IR
GRADING FEE
WAT ER SYSTEM/T'REAT'ING
SOILS FEF,
WATER SERVICE
_
PAI
M Dat���Rc¢iPt�
NEWRCSIDENTIALPLMB. SQ, IL
_
11111 '1 UTAL:
MECHANICAL PERMIT
FEE
SEI. I�C FEE
IJ
PERMIT ISSUANCE
ELE11 Cr FEE
ALTER OR ADD TO MECH.
PLUAtBf .
AIR II ANGLING UNIT (TO 10.000 CFM)
MECH A N[CAL FEE
AIR HANDLING UNIT (OVER I(LOW CFM I
CONSTRUCTION TAX
EXHAUST HOOD (W/DU(7T)
HOUSING MITIGATION FEE
BEATING UNIT (TO I TO.000 BTU)
I HA'Z'ING UNIT (OVER 100,000 B U)
IABD
VENTILATION FAN (SINGLE RESID)
Dam
RereiP. W
BOILER- COME OHP OR 100,00111' U)
'I011 S
BOIL(?R- COMP (OVER If .000 B'Bl)
AIR CONDITIONER
ISSUANCE
ISSUED BY:
DATIi
D'
NEW RESIDENTIAL MECH. SQ. IT.
TOTAL:
OFFICE