20835 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pn�'ert Idrmilicati.n PEKbfrr NO.
Building Add ness: II J n O 8 3 C
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sun n cine /nA� A A
S Dle r 25-6 13 CITY OFCUPERTINO-BUILDING DIVISION
e°lit .r'sNam: Lie.No APPLICATION / PERMIT F
KJ � I A C Z SOO BUILDING-ELECTRICALPLUMBINGhfECHAMCAL CATEGORY CONTROL#
Architect/Engineer. Lic.Na:
`Q'ii' ^',^° ELECTRIC PERMI77' "- '• �,, FEEa BUILDING PERMMIT.INFO.
Address: PERMIT ISSUANCE yam' ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter9(comment APPIJANCESRESTDENHAL JOB DP5CRB'TTON
ingwith Section 7000)of Divlsion3ofthe Businusand Pmteui.nsCode,and my
li=1stnfuu .rce and eeea. _ PANELSLC= L ,
Date Contractor
ARCHITECTS DECLARATION 701-1000AMPS
OZ I understand my plans shall be used as public records. OVER]000 AMPS SQ.FT.FLOOR ARTA b/SQ.FT.
O
z U I Licensed Pro/essbml SIGNS ELECTRICAL
Z=� OWNER-BUILDER DECLARATION
S�Z I herebyafflrmthat l amexempttmmthe Contractors License Law forthe SPECIAL CIIICNT/MLSC
fofowing Mason.
(Section 7MI5,Businessand Pmfexii Code:Any city or TEMp.METQ20R POLE INST.
pp countywhic mquircsaper ttocrostmct,alter,improve,demolish,orrepair
anystrucrom prior to its issuance,alaorequires theap heantforsuchperiNtm POWER DEVICES
Yy CC^V fie a signed statement that he is umnsee pursuant the Provlliov)of the �,,a,
._ .. Contractor's Liccve Law(Chapter9(commencing wl ,9eRbn )of Divl y�y�hgNG POOL ELECTRIC i-[J
_C3 n3ofthe Business and Pmmsto.ro Code)orthath uexempt th mal"d I VALUATION
s<G the basis for the alleged exemption. Any,vlot-ati.r%f Sectlon$ I.S)f deny OUTLETS-SWITCHES-FIXTURES
applicant fora permit subjects the apelkant toaavil penalty of me than
-m five hundred dollen(ASfyB. ?� NEW RESIDENTIAL ELECTR SQFI. STORIES TYPE CONSTRUCTION
?$.. FI,as owner o!the roperty,'or my employees w,h wages as their sole
:Z compensatfon,will, t orkandthestrunum of Intended or offered for
.'^.p sale(See 70K Business lid Professions Cud_ eContraaots License law
docs not apply to an owner propertytwQo wit s or improve thercoR and OCC.GROUP RFS.UNITS
whodoessuch work himself thmugh hisownemployees,prpvided tv"'iib Grp.
improvementsamr intend roffered forsale.I howeverthe IdingoI TOTAL: xlL
improvement tssoid withinoneyearolcomp etbn,t ¢e �u1e Blhave „
th,e�urdenofprovingtha[he did not bund)p pr�4}1°ve,, purp3st lvie.I. QTY. w'�!}'-.PLUMBING PERMIT;a'r_' ? .yFEE'" FLOOD ZONE APN
L�S as owner of the property,am excl+!u ly✓pntracting wit lizzif PERMIT ISSUANCE
contraction,to couwct the project(Sec 7 Busio sss and Profession Code:
The Contractor's Llrense law does sat app y to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
wilds.r improves thereon,and who contracts for such ptojeces with a „f.FEE SUMMARYI
c,,LLtfT.&.,(a)Gmnsed pursuant to the Cmdracor'e License Law. BACK FLAW PROTECT.DEVICE e
LJ I am exempt under Sec. B h P C for this reason £ OUTSIDE
FELS
DRAINS FLOOR ROOF,AREA,CON I. SANITARY Y N_
Owner Date RECEIPT N
WORK MAN COMPENSATION DECLARATION Ff%7lJftES PER TRAP SCHOOLTAX Y N
�1 hereby affirm that I have o certifrrate of consent to opytherre,(S . RECEB'I'M
e artlfiabC.WorWpq nationlral tali ora rercilledco thereof(Sec.
Pe PY GAS F.A.SYSTEM-1 WC.4OUTLETS PARK FEE Y_ N_
Policy abCJ WP90 �F9a�to�-o1 RECEB'T#
I'oltry# GAS E.A.SYSTEM-OVER 4(EA) BUILDI.UG DI VISION FEES
c.m any
�Ceniied copy is hereby furnished. CREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy is filed with the city inspection division.
CERTIFICATE OF IXEMPTION FROM WORKERS' I GREASE TRAP PAID •(
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA pOFI Date RC'Cel t# el LAL3
(This aecti.n need not be completed Bthe permit is for one hundred dollars
(S100)onleu.) WATER I-lEp•I.¢tlN/vFN.I./ELEcrR ENERGY FEE Y_ N_
I mHy rtthat in the performance of the work for which this perndt is bsucd,
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation laws o(Califomia. PAID
Date
Z Applicant NEWRESIDENTTALPLMB. SQ.FT. Date Recei t#
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
— O should become subject to the Workeni Compensation provisions of the Labor TOTAL:
Ytl) Code,you most forthwith comply with such provision orchis permit shall be,_ FEE
> mre
3�
seeed v°ked. a
L
CONSTRUCTION LENDING AGENSEISMIC FEECY �-Y1
L O Ihercby affirmthat
rw there 6aconstnctlonlending agency for the perform- TOTAL: ELECTRIC FEE IW
J Z anceer'sNwork!or whish this permituBsued(Sec.3097,CIv.CJ _ `�. PLUMBING FEE �fn
O Lender's Name
H Lenders Addr°ss QTY. --,MECHANICAL:PERMIT!'.„ -"FEE:'., MECHANICAL FEE
WIcentilythat l have read this appliationand state thattheabove information FEES PAID:
1 Ecorrect.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE
>- relating to building construction,and hereby authorize representatives ofthk
N ALTERORADDTOMECH.
Z city to areupone .theabovemnify an
property inspection purposes. Datil Receipt#
(We)agree o save,Indemnity an d keep harmless the City of Cupertino
against Eabil ,pdgments,costsand expenses whish may In anywayaccrue AIR HANDLING UNIT GO 10,000 CFM) SUBTOTAL:
agairetsii sequence Pth anting githis permit CONSTRUCIONTAX
AIR HANDLING 11NTf(OVER]0,000 CFM)
ignatia eo Appliant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store.,handle hazardous HEATING UNIT(TO 1(0,(00 BTL) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the ffs.�
Health and Safety Codre�9ection25532(a)? HEATING UNIT(OVER 100,000 STU) TOTAL' Tx
F-1Yet (_ry No
Wiiltheappliant or future building occupantuse equipment ordevims VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which rend,hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP OH11 OR 100,000 BTU)
4Ycs ;j No
havercadthehaz{Tousmteria regiremcn underChaper695°! BO LER-COMP(OV[R]00,000BTU)
the California Health k Safety Code,Section 25505,25533 and 25534.I -,-
uederstandthatifthebuildingdoesnotcurrentlyhaveatenant,that it is my NEWRESIDENTIALMECH. SQ.FT.
responsibility to notify the occupant of the requirements which most be fret
Priors ncc f a Certificate of Ocmpa ocy. `l�tr
LAPL:ZP 955 eta:,
Owns or authorired agent to TOTAL: ISSUEDBY:
OFFICE COPY