21702 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildingProject Identification i Jsj - PERMIT NO.
'7 Building Address: L�� fry 0 Gn
-//837 /rE t� GY G
nci. ame: / one: A A
4W&40 LNG /S' ie N..G CITYOF CUPERTIN6BUILDING DIVISION
Conlractora Name: LIc.Ne: APPLICATION / PERMIT
A �9T�q7 BUILDING-E.ECTRICALML BING-MECHANICAL CATEGORY CONIROLNN
rcyj(e,.t/Fsglneee – Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO neaetaIFRh1TI55UANCE
LICENKf DECLARATION
L-
I herebyam700M.I ivisionsedunderprovland Pro Cssmins od,iin'nc AITIlANCFSRESIDENCIAL JOB DFSORBrIION
Ingwlth5cc[Ion7000)0l Divlston3oHhe Buslnessand Professions Coda and my L
licmn.is in hill re a effect rnNEvs
LicerseCi...� jr.# y3(Zf)
Data Contactor UP TO 2DOAMPS
ARCHITECTS DECLARATION 201-1000AMP5
�q
mV I understand my plans shall be used a public records. OVER I000 AMPS SQ.Fr.FLOOR AREA f/SQ.FI.
0 CO
Ez" Licensed Professional - SIGNS ELECTRICAL
6� OWNER-BUILDER DECLARATION $I'ECIAL CIRCUIT/MISC L
Ihembyaffrmthatlameaemptfmmthe Contator'a Limn.Thwforthe
7 O.,q"q following reason.&dlon 7 01.5,Buslnew and Professions Code:Any city or
FZE'u( county which requires a permit tomnstruct,alter,Improve,denolbh,oreepalr 7FMP.ME"TQt ORIOLE INST.
�Eg anystructure prior toitshssuancq alsorequim theappllant for such permit to POWERDAUqS,
prNL filo a signed statement that he Is licensed pursuant to the provisions of the
W�n`rn Contractor's License Law(Chapter9(commentlng with Section 7000)of Dlvl-
t, O skr3ofthe Business and ProfessionsCode)orthat he is exempt therefromand VALUATION
4 �S the basis forth.alleged exemptkm. Any violation of Section 70]1.5 by any
N ccuWh44�s appllantfora permit subjects the applicant to a civil penalty of not more than OUTLE
Eu fivehundreddollars(5500). NEW RESIDENTIAL ELECTR STORIES) d TYPECONSIRLCTION
❑I,as owner ll o t property,or my employees with wages a thele sole
compenauen,w111do1he work andtheswcture bract intended or offered for DATE as,/
O vlo(Sec. pply to alnew and-Pr roperty Code:Tk Contractors License I�w
does notapplytoanownerofproperty whonemcarimproves tkreon,and
nm
� who dochworkhlnuelf orthmngM1 his ownemployces,provided that such OCC.GROUT' RES.UNITS
Improvements arc not Intended or offered for sale.If,however,the building or TOTAL:
improvement is sold within one yearofcompletlon,the owner-builder will have
t"eclen of proving that he did net bund or Improve for purpose of sales). QTY. PLUMBING PERMIT FEE
LJ L as owner of the property,am exclusively contracting with hoemed F7.00D ZDNE. APN
contractors to construct the project(Sec.7066,Business and Profewiom Cade: PERMIT ISSUANCE
The co
Contractor's License Law does not apply to an owner of property who ALTER-DRAIN 6 VEM-WATER(EA)
W Ills or impva thereon, and who contracts fee such piojects with a
o9a4actor(s)Banned persmntiothe Contactor•Llmnae Law. BACK FLOWPROTECT.DEVICE FEE SUMMARY
L_J I am exempt under Sec. B 4 P C for that mason
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
• Owner Date re w a RECFJPr-
WORKMAN COMPENSATION DECLARATION FIXNRpg PER TRAP SCHOOL TAX Y N
❑I hereby affirm that I have o lrtumte of acedif d pythe REcOTT N
3800,�Aiflate of WorLere'Compensatlonlnsuranm oracertlfkd copythereof(Sec. GAS EA.SYSTEM-1 INCAOUTLEIS PARKFEE Y N
Polk Late CJ4/"'-25-0 dyL' RECEIPT
COany GAS EM
EA.SYST -0VER d(E.A) BUILDING DIV]SION FEES
CJAlflcd copy is hereby tthe cid. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
�C sifted ropy b(14d withh the city Impcdion division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRF'1'SE TRAP PAID /�.5�
COMPENSATION INSURANCE SEWS&SANITMY-STORM E,A.200(+C. Date RCtt'1 tk N
(Ehissedien need nut k mmpleed of the penmit b foronc hundred dollars
a1I0)nrlewd
WATER HEATER W/VENT/E.ECTR ENERGY FEE ' Y N
I m.s leshat an the performance of the work(orwhlch this permit b blued,
1 shall not employ any person In any manner m as to become subject to the WA.�s,STI/TREATING
O
Workers Com,..tien Uwsnf California.Date PAID
Z NOTICE
Z Z AOlicant MPLICANT:If,after making thio Certlflate of Exempllon,you NEWRFSIDFMIALPLMB. SQ.FT. Date Recei tff
Fshould bemmcavbjen to the Workers'Compensatlun provlslons ofthe Labor TOTAL:
W Code,you most forthwith comply with such provisions orchis permit shall be BUILDING FEE y�
W > deemed revoked. SEISMIC FEE _116-1
�-
CONSTRUCTION LENDING AGENCY agent
CL � Ihereby a(Brmthat there Lsamnstructlon lending agency fortis perform- TDTAL: ELECTRIC FEE 76 a�
Z anceefthe work lorwhichthispermltbls d(Sec.3097,CIv.C.) —
O Lender's Name /a/// PLUMBING FEE O dS
LL h Lenders Add.. - QTY. MECHANICAL PERMIT FEE MECHANICAL FEE 70 36
O W icdifythatlhavereadthbappli&tt.nandcatethatthu.wvenfornutlon
bcomeet.I.grecmcomplywithallcityand countyordlnanmandstatelawa PERMITISSUANCE FEES PAID:
} N relating to building construction,and hembyauthorlee mpresentativesofthb
F- Z city to enter upon the above-emntoned properyfor inspection purposes. ALTER ORADDTO MECH. Date ReCel [M
_ (We)agree to ave,indemnify an d keep harmless the City of Cupertino P
against liabilities,Judgments,costs and expenses which may lnanywayaccrue AIR HANDLING UNIT CID 10,000 CFM) SUBTOTAL'
agalnstald City s nao ek graining ofthlspermlt.
AIR HANDLING UNIT(OVER 10,000 CEM) CONSTRUCTIONTAX
Signamreo cant/Contractor /We EXHAUSr HOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOS E
Will theapplicant or future building oavpant stare or handle hmrdous HEATING UNIT(TO 100,W0 BM Date Recef [N
material as defied by the Cupertino Municipal Coda Chapter 9.17,and the
Iimlth and Sifty Code Section 75537((.)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes M No
Will the applicant or Future building occupant use equipment or devices VENTILATION FAN(SINGLE RF_SID) IS DATE
which emit hav rdous air cents militants as deft red by the Bay Area Air r/s,��
• Quality Management District? BOILENCOMP OHPOR 100,000 BTU) FEBI
4havcyrs readthehvardouomaterialsrequircmentsunderChapter6.95of MOILER-COMP(OVERIM'"BTU) 1 y 1 {1 991
the aI forms Heath k Safety Code,Se tlons 7550.5,5533 and 75536. I
tied cats rad that if the bu ild hill does not carmmly have a tenant,that it is my NEWRESIDENTIALMECIL SQ.FI'. /1 he req
{/�
primtobnit Ify tof panty.lrementswM1icM1 Fane nra't Wq 01 rjjPPFlinll
mspmo101ityt f IB of Ocmpa racy. / ,
Owneror odsd agent Dat'
TOTAL: ISSUED
OFFICE COPY