24208 APPLICANT TO FILL IN INFORMATION WITHIN RED_ LINES — USE BALL POINT PEN,ONLY '
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Building 1.O9$uilding Pm'ert Identification �� PERMIT Nq, 0 '
vera ara/e: o one: -- Z
�fB/1//,4 Q�e� CITY OF CUPERTINO-BUILDINGDIVISION
Con actor'aName: Lic.No: APPLICATION / PERMIT
BNLDINC-ELECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL N
Architect/Engineer: Lie.No:
„ !IQTY 4.t yt ";ELECTRICPERMITq=r ° 'FEE' ,t BUILDING�IIERMIT,'INFO '
Address: - - -
" - - - PERMITISSUANCE- - ,- � ..� -
LICENSED CONTRACTOR'S DECLARATION
IherebyafGrenthet l am Bcensed under provisions fCh pt r9(commenc- APPILANCESRERDENHAL - JOB DESCRE'TION
ing with SeMon 7000)of Mvision3 ofthe Businessand ProfeaslonsCode,and my - -
licenxlslnfull force and effect. - - PANELS e
LicenseClaas .Etc.X
Date Contractor UP TO 200ANTS
AncxaTECPs DECLARATION
201-1000 AMPS
aO Zp❑ - I understand my plan dull be used as publicublicr records OVER 1000 AMPS '
SQ.FT.FLOOR AREA $/SQ4FI.
Fi tj Licensed Professional _ SIGNSELECTRICAL
�<<Q OWNBR-BUILDER DECLARATION - SPECIAL CIl2CUIT/MISC' - 't
zy. 7a Iherebyafflrmthatl amfrom the frothe Contractor's License lawforthe
pO following reason.(Section 7011.5,Business and Professions Code:Any city or
Fzl"t� countywhlch requires a permit to construct,alter,improve,demolish,or repair TEMP.METER OR POLE INST.
4 any structure prior to its issuance,also requires the applicant for such permit to
q ,��j1 POWElt DEVICES
'F Mile a signed statement that he b r 9(cournew.cuant to the Aon 7000) of the _ -
Contractor's license Lew(Chapter 9(commencing with Section 7000)of Divi- VALUATION Y
1n SWIMMING IC)DL ELECTRIC
��0a sion3pfthe Buaineasand Professloru Cpde)orthat he Vexempttherefromand
O the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHFBFIXTURES - •�/l/
applicant fora permRsubjects the-applicant to a civil penalty of not more than
a undyed dollars($500). NEW RESIDENTIAL ELECTR SQ.FT. r STORIES -- TYPE CONSTRUCTION
v as owner of the property,or my employees with wages as their sole.. '
p pensation,avRl do the work,and the strumae is net intended or offered for 1FIN
'$ q as a(Sec.7044,Business and Professions Code:The Contractors License Law -
2 does not apply to an owner of property,who builds or improves thereon,and (�N, �AAAMHRMiT,'
a�.`.'�� IT C
e,3.. who does such work himself ortheaigh his own employees,provided that such V . ''OCC.GROUP RES.UNITS
improvements are not intended proffered for sale.If,however,thebuilding or Tp
Improvementissoidwithlnoneyearofcompletiomtheowner-builderwilthave ''-
the refers of proving that Mdid net build or Improve for purpose of sale.). Qjy, p =i '�'PL FLOOD ZDNE APN
�L as owner of the property,am exclusively contracting with licensed p. IT ISSU
contractors to construct the project(Sec.7044,Business and Professioru Code: _The Contnaor's License law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(FA)
Wilds or Improves thereon, and who contraM for such,ptojects with'i •156 .GSI s` "
,,fi�t. et (a)licensed pursuant m the Contractor's License Law. ,. FEEtSUMMARY.
LJf am exempt under Sec. B &-P C,for thin reason BACKFLOW PROTECT.DEVICE
Owner - - - DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Date RPLEB'T k
WOR KMAN COMPENSATION DECLARATION FIXTURES.PER TRAP V, SCHOOL TAX. ' Y N
❑I hereby afflrrn certificate that I have a of consent to self-insure,ora Y T X
certilicate of Workers Comperuatlonlruuranceoracertifkxl copythereof(Sec.
3800,Lab C.) GAS FA.SYST�M-1 INC.4OUTLETS PARK FEC Y 'N
_ -
Policy p GAS EA:SYSTEM-OVER 4(FAJ RECEIPT p
Com any BUILDING DIVISION FEES
- CertlOed copy is herebytdl GRFASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
❑Certified ropy is filed withh the the city Inspection division. - _
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP - PAID
COMPENSATION INSURANCE SEWER SANITARY STORM FA 200FT Date Recei tit f
(This section need net be completed lithe permit bfor one hundred dollars
($100)or leas) " WATER HEATER W/VENT/E.F-CTR ENERGY FEE. Y N
I certitythat in the performance of thework forwhich this permit is issued, .
•' _ I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREAITNG
- Workerv'Compensation Laws of California.Date PAID -
ZZ NOTICE TO
If,after of Exemption, NEW RESIDENTIAL PWB. SQ.Ff. Date Remi t# " ,
NOTICETOAPPLICttotheWorkrs'Co pesationlcatedsomoftheLyou
should become subject to the Wpfxera'Compensation provislow o(the Labor � � TOTAL: .1
'X tl) Code,you resat fnthwitli romplywithsuch provhlonsor this permit shall W BUILDING �
W 7 deemed revoked. - ,
a G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency for the perform ELECTRIC PEE
Z- ance of the work for which this permit is Issued(Sec.3097,Civ,C.) TOTAL '
. V'O Lenders Name • - .t.}. PLUMBING FEE
u- Lenders Addreas QTY. +''•MECHANICALIPERMIT.`' , ','FEE,t MECHANICAL '
OW- I es Aifythatl have readthis application and statethatthe above information
. a incorrect.I agree to comply with all city and county ordinanres and slate I.. _ PERMITISSUANCE FEES PAID:'
relating to building construction,and hereby authorize representatives ofthis -
Z, city to enter upon the above-mentioned property for inspection purposes. ALTEtORADDTOMECH. -
_ - (We)agree to save,indemnify and keep harmless the City of Cupertino - - Date •.Receipt#
sgiinstllabilities,pil v,"gas dex nseswhich nu anywayacems AIR HANDLING UNIT 10,000 CFM) SUBTOTAL: '
again s ity consapbe ce of thentingofthla perm _
V AIRHANDLING UNIT(0VERI0,0D0CFM)' C N ION TAX -
wmrco pelican anor Date EXHAUST HOOD(W/DUCT) - CONS UCTION TAX PAID:
HAZARDOUS ATERIALSDISCLOSUR[ ' - '
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)'
m ,
aterial as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date Recel t#
Health and Safety Code Section 2S532(a)7 HEATING UNIT(OVER 100,000 BTU) - TOTAL:
❑Yes h No'
Will the applicant or future building occupant use equipmen[or devices VENDLATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as deflned by the Bay.Area Alr
Quality Management District? - BOILER-COMP CHIP OR 100,000 BTU) A p
4 Ves No A
hevereadthehaza ousmaterialsrequimm nNunderChapter6.95of BOILER-COMP(OVFR 1110,0(10 B711). I D
the California Health&Safety Code,Sections 25505,25533 and 25534.-1.' ���
• � understand that if the building does not corrently have a tenant,that it is my NEWRFSIDEMIALMECH. `S .FT w
responsibility m notify the occupant of the requimmena which must be met F�
Prior to issuance of a Certificate of Omopanry.r City
I v4
Owner or authorized agent '.'Date - ISSUED BY: "-
TOTAL:'
OFFICE COPY .