20150 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Address: ^O a� t5r 0
21-1 I L v G n G I
w era came: one: _
.e CITYOFCUPERTINO-BUILDING DIVISION , J �,flIq
. contractor' ante: Lie.Nm APPLICATION I PERMIT 7 �/
V'Y�V1'x n / BU[LDING7].ECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL M
Amhltect/Engineer. Lee.No:
QTY ELECTRIC PERMIT FEE .BUILDING PERMIT INtP,`
Addreas: PERMITIRSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Iherebya(flrmthatl.lkeneedunderpra W.Bof Chapter9(mm mc- APPLIANCFSRESIDENTIAL ]OB DESCRIPTION
Ingwithim ollf..ofd efelon3otlhe BuslneseandProlesaloneCode,end my ���
license ls e fun fora and effect. PANELS
LicenseCls® Lic#
Date Contractor UP TO 2DOAbTS
ARCHITECT'S DECLARATION 20M000AMPS
q�v aO Zpp I understand my plans shah lx used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.Fr.
Fi U Licensed Professional SIGNS ELECTRICAL E D I IV
Q OWNEReBUILDER DECLARATION
SPECIALCIRCUIT/MISC
71.., owingrason.lhatramexempifromthe Contractors Code:icense Law for the
pp o following reagn.(SMlon 7RI1 S,Business and Professions Code:Any city or
F7E. county which requires a permit to construct alter,Improve,demonsh,or repair TEMP.METER OR POLE INST.
any structure prior to its Issuance,also requlrea the applicant for such permit to
o POWER DEVICES
file a signed statement that he as licensed pursuant to the provlsiom of the [fJ V
3r„ Cnetrector.License Law(Chapmr9(ou.nd.Swith Scel7000).f Divi- SWBdMING(VOL ELECTRIC
ATION VALU
viOQ on sion3ofthe Bushesseand Profeaatota Carie)orthat helsexampttherefromand
•..a� the heals for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHFSFEKTURIS
< applicant for a permit subjects the applicant to a civil penalty of not room than
fivehundred
ownerdelta.of
pr. NEW RESIDENTIAL ELECTR SQFT. SIOWES TYPE CONSTRICTION
�n ❑I,ae owner of the property,or my employees with wages as thele sole
.]a&
compensation,will do Businethe work and the structure Isnot Intended or offend for
O
.]a&,appy to anowandf property Code:The Contactors hemelaw
does$$ whodotapply loan owner of throng hiswho
nemoyImproves
ovided that such
OCC.CROUP RFS.UNITS
whoovessuchmnts amwork himself dedoraugh hlsowge.If,however,
thedihatgor
Improvements Budd
ithmoneyearofcomplrroffered llem,the ow ev bullderwilingor TOTAL:
Improvement ls sold within one ymrofcompletlon,the rwner-bullderwill have
'hAmrden of proving that he did not bund or improve for purpose otsale.). QTY, PLUMBING PERMIT ", FEEFLODDZANE APN
Lj L as owner of the property,am exclusively contracting with licensed
contractor to construct the project(Sec.70K Business and Profaniota Code: PERMIT ISSUANCE /II,OO
The Cmdactea License Iaw does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) d
builds or improves thereon, and who contracts for such pRojeata with a - ,
antrader(O homed puauam to the Contactors License Law. FEE SUMMARY
0I am exempt under See. B &P C for this mason BACK FLOW PROTECT.DEVICE
•
DRAINS.FLOOR,ROOF,AREA,GOND. SANITARY Y N-
FITS
Owner Date RECEIPT M
skem�'' WORKMAN COMPENSATION of
FLYNRES-PER TRAP SCHOOLTAX Y N
Iia hereby affirm that I have i certificate of consent to op there. ora RECEIPT M
art1(I.bC.Worken'Compereatlanlwuranm orannifled copy thereof(Sec. GAS EA.SYSTEM-I INCA OUTLETS PARICFEE Y N
Poli3800,Lab C.)
Comryan GAS F.A.SYSTEM-OVER 4(EA) REND DI V
Maraifiadeopylshereb furnished. M BUILDING DI VISION PEES
�Certifled copy Isfiled-Mth the city Inspection division. CRGSE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE Of EXEMPTION FROM WORKERS' GRFASETRAP PAID
COMPENSATION INSURANCE RMSEWdj SANITARY-STORM F.A.200FT Date Recei tit
s lection need not be completed If the permit L+lor one hundred dollars
($100)rtifyt a WATER HEATER W/VFNT/MECTR ENERGYFEE Y N—
I
not thatInthe performance pamonInytmannerhe work for rob. subjrmitect
isIssued,the
I shall not employ any penan in any manner m u to become gbject to the x.00 PAID
Workers'Compensation Lawaof California.Data WATER sysTlmT/TREANc
- j •p
ZZ Applicant NEWRESIDENTIALPLiB._ FT. Date Rece1 t#
O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
F should become subject to the Workers'Compensation provisions ofthe Labor TOTAL:
a. to Code,you moat forthwith comply with such provblora orthls permit shall beBUILDING •
LU ] deemed revoked. -
CONSTRUCTION LENDING AGENCY SEISMIC FEE
Q. Ihereby affirm that there is.romiruction lendingagenry for the perform- ELECTRIC FEE
Z arm ofthe work forwhich this permit le isged 6m.3097,CIv,C.) TOTAL:
V O Lerder.N.ms PLUMBING FEE
LLF Lerder.Addem. QTY. MECHANICAL PERMIT '-FEE MECHANICAL FEE
Iadlfythatl have mad this application and pate that the above Information
O W
fl iscorrect.I dgmato comply with all city and county ordinances and nate laws PERMrrrSSUANCE FEES PAID:
} N relating to building construction,and hereby authorize representatives of this
(_ Z city to enter a Pon the above-mentioned property for inspection pe rposes. ALTERORADDTOMECH. Date Reeei IM
V — (We)agree to save,indemnify an d keep harmien the City of Cu Pert ilio P
ag.rat b111tMa,pdgmenb,costsand expenses which cosy Inany wayaaroe AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL'
against Id Cityl n uenre
the granting of this pertnit AIR HANDLING UNIT(OVER IO,WO CFM) CONSTRUCTION TAX
mot pp lit o tractor `Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or futum building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCtei Ik
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL-
1-1 Yn M No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE miRESID) 1�$[I�"DATE
which et hazard...air contaminants as defined by the Bay Area At, @
Quality Management District? BOILER-COMP OHP OR IWOOD BTU)
Yee ❑❑No �`��
have red the h &Safat mmde Scetequiremonts underand2MChapter 1:95 of BOILER-COMP(OVER 100,000 BTU) APR J
the Glunderstand t HeatthASldin Code, Socia currently
have
ternd25534.1 APR
empmuiandthatlfthe ally thee.part notof e requir have.tenantthat b Is my NEW RESIDENTIAL METH. SQFr.
rmpoto issua reffillity to,
of aCeheieste o Occupe requlrcmeniawhich at be rrcl _ of CuDer{,no
- prior to issuance ofa Certificate of Ocgpanry. 1 4 Lti
Owner or authortzed agent Data 155 L 1�La
TOTAL:
OFFICE COPY