23956 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
tluiMin Pni'e't Identifkalon
Building Address: PEt\f;T ND.
23956
aced: neer.
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� � CITY OFCUPE Rn O-BUILDING DIVISION '--t 0�{'L
°n'e °"N'rn" Le.No APPLICATION / PERMIT
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BLTLDINC-ELECTRICAL -MECIIAN'ICAL CATEGORY CONTROL�g ct/Fsg nmr. No:
.C's /ZOGirl.6t.r/ L30�gB�'Z � " .BUILD INGPERMITINFO
i
QTY �' ELECTRIC PERMIT "-FEE^^'
Adders, C/,;A S 1
X38 k/�N ><n � t
PFRIIITISSUANCE ❑
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LICENSED CONTRACTOR'S DECLARATION JI
(hereby atflnntharlam ncenxd under provisions of Chapter9(commmc API'LIANCESRESIDENTIAL
IngwithSmion 7000)o(Divblen3o(the Buslneuand Pro(e,alom Code,and my JOB DESC.RBTTON
license b m fvnJyc;and direr 'P/e SGt,l-- PANELS f'1 a R'SSi) moi\
License Class LWca g hJ X�J����aiV
Dae Conmator
ARCHITF,CPS DECLARATION 701-1 ON AMPS
�OOte Z Iunderstand my pians snail be usM As Feline OVERIOOOA,MPS SQ.FT.FLOOR AREA 5/SQ.I7.
Licensed Professional SIGNSELECTRICAL
<<Ei
OWNER-BUILDER DECLARATION SPECIAL CIRCL77/MLSC
n�/ Iherebyaffirm that l am exempt from the Contl License lawfor the
^Q fallowing reason.(Seetion 7(31,5,Bteondel Pmf¢ssions Code:Aaymyor q''MP.MEI'Qt OR POLE(NST.
n countywhichrequousa permit tommtmM,lt,r,mpmve,demdbh,arrepair
�- anystrecture prior to its histance,also requires theappliant for such permit to
V file a signed statement that he Is licensed pursuant to the provisions of the POWER DEVICES
�O� Contractor's License Law(Chapter 9(commenMg with Section 7000)of Divi- SWIMMING(VOL ELECTRIC
5 < sion3ofthe Business and Prdeal Codeine that he bexmpt therefromand VALCATION
50•.1 the hue for the alleged exemption. Any violation of Section MIS an OVIiETSSWITCHESFU7URFS Qd
0 'PPllantlara permit subµav the applicant toadvil peeultydnct mort than �1 Q�
f< five hundred dollars($500). NEW RE4DEYIIAL ELECTR L
S o� ❑I,as owner of the pmperty,or my employee with wage as theb sale SQ T. STORIES TYPE CONSTRCCTiON'
ompa.e.tion,willdo the work and thestruclure b not Intended or offered for
lF sale(Sec 70K Business and Professioro Code:The Cantrator,License law
0>$ does not apply to an owner a property who builds or improves thereon,and
who doessuch work himaelforthrough hisown employees,provided thatsech OCG GROLP RFS,UNITS
Improvements arenot intended oroffered forsale.If,however thebuilding or TOTAL:
improvement bsold within oneye irofcompition,theovener-builderwi11 have Q7y'SC?
th rdenofproving that he,did..Wndor nnprova for purposeofsele.). ' :'-'�` "
j BINGPERMIT. FEE.
L°L as owner of the Property,Am exclusively contracting with licensed FLOOD 7DNTi APN
contractors to construct the project(Sex,70K Business and Professions Code: PERMIT ISSUANCE
The Contractor.License Law don nut apply to an owner d property who
Wilds or Improves thereon,and who contractsfor such projects with a ALTER-DRAIN k VENT-WATER(EA)
c
Bacteria)licensed pursuant to the Contractors License La . f - � FEE SUMMARY
I am exempt under Sec B h P C !wor this reason BACK FLAW PROTECT.DEVICE
nee Date DRAINS FLOOR ROOF,AREA,CONED. SANITARY Y_ N
WORIGMAN COMPENSATION DECLARATION RECEIPT=
hereby affirm that I have a certlfiore of consent to self-imum,or a FATVRFS PER TRAP SCITOOL TAX Y N
ate of Workrs m
eCoperuari°n Insurance ora certlfiM of(Sm,copy thereRECEIPT S
+b C3 GAS EA,SYSTEM-1 INCA OUTLET'SPARKIg Y_ N_
X
Lsy S RFCE 1T N
GAEA.SYSTEM-OVER 4(EAI edified copy is hereby fumished. BUILDING DI V(BION FEES
OCertified copy isfiled with the city Inspection division. GREASE/WDUSTRL WASTE INTERCEPTOR PLANCIIECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(This section need net be completed lfthe permit b forced hundred dollars SEWER-SANITARY-STORM EA.700Ff. Date Ree t#
($10()m less.)
Icertify that In the perfomunceofthe work forwhlch tis permit is Wooed, WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
I shall not employ any person In any manner so As to become Al to the
Worken'COmpenunonlawsof Cellf.mu.Data WATERSYSfEM/TREATING PAID
Z Applicant
O NOTICE TO APPLICANT if,-her rruking this Cedffl-teof Exemption,you NEW RESIDENTIAL PL.MB. SQF7, Dale Race) t#
should become sub)dct to the Worker:Compensation peavbloru of the Labor
!n
Code,you=at fort hwith comply with such provisions or this permit shall be TOTAL:
> deemed revoked. UI IN
p CONSTRUCTION LENDING AGL'NCY SEISMIC FEE
Z I hereby affirm that there is a construction lending agency for the perform ELECTRIC FEE
O once ofthe work for which this permit isbalIS,,3097,Civ.C.) TOTAL:
fender's Names PLUMBING FEE
H lenders Address QTY- :zvi .MECHANICAL-PERMITotacx� =;FEE•. MECHANICAL FEE
U Icertifythatl have read this applicationand state thattheabove information
WW conn.I agree to comply wlthall city and count'ordinances and.state laws PERMIT ISSUANCE FEES PAID:
elatingtobulldingcomtructiral hercby..b.nor repiromutivescul
Z city to enter upon the above-mentioned propertyfor lnspetlonpurpoxn. ALTER ORADD TO MECH.
(We)agree to save,Indemnify an d keep harmless the City of Cupertino _—Date Reeeiptp
AgainstliabiOties,judgments,cretsand expenses which mayinanywayamud AIR HANDLING UNIT(TO 10.000 CFM)
against said City o consequence of the granting of this permit. SUBTOTAL:
AIR HANDLING UNIT(OVER 10,"CRM) CONSTRUCTIONTAX
paw"mll n °ntnctor p� EXHALSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:HAZARDOUSMATERIALSDISCLOSURE
ll the appllo ntorfutumbullding creepier store or handle hacardous HEATING UNIT(TO IW,000DNI
matrnal.,definrd by the Cupertino Municipal Code,Chapter 9.17,and the _ Data Recoil t#
Healthand StftyC CSSSeylon25537(x)7 HEATING UNIT(OVER Ifil RTU)
QYea L. ..T T
WIIl the applicant orfuture building occupant use equipment or devices VENTILATION PAN(SINGLE RFS ID) 155UANCE!DATE
ich emit hacardous air cm'Ununants as defined by the Bay Area Air
lity Management DW BOILER-COMP Of IF OR 100,(X3 BTU) `
Yes L—a$Nu7� N � \
+read the havNuua maleriab requlrrrrenb under Chapter6.95 of BOR,HRCO\1P(OVQtIW,tXp BILI
Q!!Ch rola health k Safety Code,Sections 25505,75533 and LS53G. I 'ifs;
r,. A d that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.IT.
.ility to natny the occupant of the requirements which must be met
a issuance d a Certificate of occupan y,
Owner or aeourt7 N agent Dae
TOTAL: ISSUED BY
OFFICE COPY