20589 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulletins Protect Identification PERMITNO.
Building Address:
1 c1 .P� 20589
TYWA— �� � '�GQ. N o G./� .
ere ams: n one: p
10 `' ..� 15 �t 2�4 CITY OF CUPERTINO-BUILDING DIVISION �j
Co ams: �
APPLICATION /PERMIT )--Set)--Set — C 0
�1nT �
� � � CATEGORY C
A¢hlte�/Engineer. Llc Na: BI1fI'DINGELECTRICA4PLUMOiNG-MECHANICAL ONTROL M
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addrea9^^ PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION of ChON
I with by affirm Secion70that)amlken.dunder p essand of Cssions9de,and(comervere.
my APPLIANCESRES[DENTIAL JOB DESCRIPTION
Iin...I Section 7000).nd died. the BudnmsandlProfessl.neCade,and m r\
Li.. la in fail rad cf# PANELS /� /
LlcanceC ss r Llcp 236337 l// (�„J
Dalentratloryr _ /1 /1LZI!TO 2DO AMPS
A HITECPS UH 1 16(' N)1-1000 AMI5
00 2. I understand my plan shag be used as public records. OVER IODO AMPS SQ.FT.FLOOR AREA /SQ.FT.
O
Licensed Professional SIGNSELECTRICAL
rn
�j- UI
OWNER-BLDER DECLARATION
�
7� Ihereece G
byafRrmtlut lam exempt Contraar's Llanwfor the SPECIAL CIRCUIT/MLSC
QQ following reason.(Section 7031.5,Business and Professions Code:Any city or
county which eequieeaa permit to com uct,alter,Improve,demoWh,.reepair ' P.METFR LE IN
O33a any structure prior to its Issuance,also requires the applicant for such permit to POWER DEV(
V file a signed statement that he is licensed pursuant to the provision of the
y, Contractors License Law(Chapter 9(mmmencingwith Section 7000)ofDiel-
L,30 sl.n3 ofthe Business and Profealmo Code)orthal he isexempltherefromand SWIMMING L VALUATION
<, the basis for the alleged exemption. Any violation of Stolon 70315 by any OUTLETSS FI
applicant fora permit subjects the appReant t... read.ell penalty of not rre than
five hundred dollars($500). NEW REBID AL EL
GGG711 �n ❑I,es ower of the property,or my employees with wages as thetr sok -
AX SOFT' SrORIES TYPE CONSTRUCTION
Ccompensation,wgl do the work,and the structure Is em Intended or offered for
'$ q sale(Sec 7044,Business and Profession Code:The Contractors License law
,$ does not apply to an owner of property who Wilda or improves thereon,and OCC.GROUP RES.UNITS
does such work himselforthrough his own employees,provided that such
Improvements are not intended oroffered for sale.If,however,the building or TOTAL:
Improvement issold within cvyearofcomp:dlog the owner-builderwill have
tlerrden of pmving that he did net build orlmpmve fm purpose of cats.). QTY. PLUMBINGPERMIT FEE FIAODZDNE APN
u L as owner of the property,am exclusively contracting with licensed PgRMITISSUANCE
contractors to mn+tmet the project(See.70(4,Business and Professions Code: _pQ
The Contractor's Llan.Law don n.t apply to an owner of property who ALTER-DRAIN k VENT-IV (EN
Wilds or improves thereon,and who contracts for such pyjeds with a
OgR[��etor(s)Rmosed pursuant to the Contractor's Limn.Law. gpq(Ff.OW OTEC E FEE SUMMARY
LJ I am exempt under Sec. B k P C for this mason
— OUTSIDEFEES
Owner Date
DRAINS A GOND, SANITARY Y N
�ftRECEIPT N
WORKMAN COMPENSATION DECLARATION ppR SCHOOL TAX Y N
❑I hereby affirm that I have•mutificatImunne of consenta"Alfi to self-instuopytherre,ora RECENT'N
ce00,Laeof W.rken'C.mperuaHon Wunnoe ora ar<ifhd ropy thereo((Sec. GAS EA. NCAOUTLEfS PARK FEE Y— N_
350, els CJ
Policy p ��� � CAS EA.SYSTQd- VER 4(FA) RECEIPT M
Co�mpane BUILDING DIVISION FEES
I ICedlfledcopylshereby rnlAM GREASE/INDUSIR WASTE INTERCEPTOR PLANCHECK FEE
��/edNM copy is filed with the city Wpenbn division.
CERTIFICATE OFa MPfSON FROM WORKERS' GRFASE7RAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 20EFTs�I Date RL'cei tM
(fhle secti.n need nut be ted complelithe permit ls(orov hundre -
d dollars V
(;100emle.') WATER HEATER W/VENT/ELECTR ENERGYFEE Y N—
I
thatoy in an person
in anftmannhe er sores to became
permit le Ito theed, —
1 shall not employ any person in any manner m as to become subfee to the
Workers Compensation Laws.( ATER SYSTEM/TRFATING
California.la.Date PAID
O Z Applicant NEW RESIDENTIAL PCMB.__SQ.FT. Dale Recei IM
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
hshould become subject to the Workers'Compenation provialdv of the Labor TOTAL:
W Code,you mu at forthwith comply with such provision or this permit shall be
W > deemed revoked. D
W
a CONSTRUCTION LENDING AGENCY SEISMIC FEE
IL Ihereby affirm that there l,a construction lending agency Settle,perform, ELECTRIC FEE
Z ,mm.f the work to,which this permit is Banned(Sac.3097,Cle.C.) TOTAL: _civ
C O Lenders Na ar• PLUMBING FEE
LL != Lenders Address QTY. MECHANICAL PERMIT FEE .v
O Sid
Icedifythatlhovereadthbepplicatbn..c1suethattheaboninformathm MECHANICAL FEE
1 l,corrM.)agree to comply withal)cityand county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>- N relating to building construction,and hereby authorize representatives of this
I" city to enter a Pon the above-menttorted property for Wpartlon purposes. ALTERORADDTOMECH.
Z
Z (We)agree to save,indemnlly an d keep harmless the City of Cupertino Date Receipt#
%alestliabilities,'pdgments,"..ad expert.which may m.eymyereme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: •Q
Tal
b Id C1 In eqi ens.(the granting of thlep It.
1( (p_ �(Jrl) AIR HANDLING O,W
NG UNIT(OVER IOCFM) CONSTRUCI70N TAX
Slgvtureof Applicant/Commeter DA, EXHAUST HOOD(W/DIKT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future bugdingocaupant store or handle hazardous HEATING UMT(TO 100,0DO BTU)
material as defined by the Cupertino Municipal Code,Chapter 911 and the Date Recel t#
I Iealth and Safety Code 9,5en 25537(a)i HEATING UNIT(OVER 10,000 BTU) TOTAL: 0
0 Yes o
WIlllhe applicant or M.building occupant use equipment ordevim VENTILATION FAN(SINGLE REBID) ISSMMDATE
which emit hazardous air costa nets as defined by the Bay Area At,
Qu aIity Management Dista BOILER-COMP(3I(I'OR 100,IXp BTU) �� 'I t�
Yn JUN 2 V lJ�u
have read the I, .zea material,requirements under Chapter 6,95 of BORER-COMP(OVER 100,000 BTU)
the
understand
to Health building
Code,Seelon25505,25533and25534.1
understand that If the bWlding does not currently have atenant that ltl,my NEW RESIDENTIAL MICCH. SQ.I.7
ro ovlbllitytonchlythcoccupard fthemcf irementewhichmus9bemet City,of Cupertino
u t.l anmof Ce Ocateo ccupaocy. G f c Me P
Owner or authorized agent I Date •U ISSUED BY:—�J_ V
TOTAL:
OFFICE COPY