21262 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building AdO.ress: /'�aI n("1/�
d` r GIGVMG
n r one:
CITY OF CUPERTINOLBUILDING DIVISION -� /'1/j+O
Contractorme:.NaIt,,No: APPLICATION /PERMIT 7
BUILDING-ELECTRICALPLIIMBING-MECHAMCAL CATEGORYCONTROL M
Amhltect/Engineer. Lk No:
QTY ELECTRICPERmrr FEE, .BUILDI PERMIT INFO
Address PERhIITISSUANCE ❑ E ❑
LICENSED CONTR under rDECLARATION '
I herebyith Sectio 7000)tlamecen3 ofthe erprovlaions nd Pro Chapler9de,and c APPLIANCESRESIDENTIAL JOB DFSCRIPITON
it sai.l.fon7W0a.de Mon3o(the Bualnessand Pse(esaloneCode,and my
11e,na l.ln full and Mfect. b�lz. PANES
L=Class— LION _ ()
D'te Contractor C./C-a�ri Z
ARCHITECTS DECLARATION 211-IODOAMPS
q�q�uu�7O. ]understand myplans.hallbeused es public.rda OVER1000AMPS SQ.FT,FLOOR AREA $/SQ.FT.
Fi Licensed Pmfessionsl SIGNS ELECTRICAL
<<�<N OWNER-BUILDER DECLARATION SPECIAL'CIRCUIT/1,119C
,7 F, � IhercbyafOrtnt}utlam exemptfromthe Cont ractore Lluna Law(orthe
pp following reason.(Section MIS,Business and Pmfesstom Cods:Antl or
07t-. alter, y ep TEMP METER ORIOLE INST.
CountY�M anystm mpdarraqulresatoits6 mlttomnslmd,mquireatheapli=tfmsuch,orretto
anyatmeture prlortolts issuance,ehorequlrealhe applirantfw�uch perMtm POWER DEVICES
ryE Ale a signed statement that he ts licensed purauant to the provisions of the
�O q Commun's Licence law(Chapter 9(mmmencing with Section 7000)of Divi-
OS uon3 of theBuMnessand Professions Code)orthat he is exempttherefromandaM M SWIMhIING POOL ELECTRIC VALUATION
-
the basis for the alleged exemption. My violation or Section 7MIS by any /') OOO
appuntfora permit subjects the applicant to a civil perafty nmarc than OUTE4FT
LETS-SWITCHXTURE5 1
❑ Ave hundred dollars($.5500).
$ 1,as owner of the property, NEW RESIDENTIAL ELECTR SQ.FI. STORIES TYPE CONSTRUCTION
�n ❑ p perry,or my employees with wages as their sale
C 6 companaHon,will do the work and thexmucture is not intended or offend for
9 ❑ ale&c,70K Busbie..and Prfemloru Code:The Contractors Limr Le w
does not apply to an owner of property who Wilda or improves thereon,and OC
CC who does such work himself orthrough his own employees,provided that such C.GROUP RES.UNITS
Improvements are not Intended oroffered for sale.If,however,thebuildingor - TOTAL:
improvement bsold Mthinoneycarofcompletiomtheowner-buBderwlll have
tIA,unden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE IT.00DPDNE APN
LJ L as owner of the property,am exclusively=trading with licensed PERMIT ISS(JANCE
onnt-d-ratomnstruct the project(Sec.7044,Business act Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EM
or Improves thereon, and who contracts for such p(ojeMs with a
rts)Bcenad pursuant to the Contractors Lt...Law. FEE SUMMARY
LII am exempt under Sec B k P C for this reason BACK FLOW PROTECT.DEVICE.
DRAINS.F'IAO REA,COND. SANITARY Y N
Owner• Date R ROOF,A
WORKMANRECEPT X COMPENSATION DECLARATION FIXTURES PER TRA 5CI100L TAX Y N
�Kereby orkcm that 1 have o lmum to of consent m opytheroo ora RECEIPT p
3800,ceAtflateo(Workere'Compensatlan[nsurane,oracertifled copythereof(Sec GAS,EA SYSTEMI INCA OUTLETS
3800,Lab CJ PARK FEE Y N
rmtry x 1 14fl?TS'1 —9D RECEIPT w
Com an 41r9 C'mm�Ga4r3 run r9rsf - ice CAS EA.SYSTEM-OVER4(EA) BUILDING DIVISION FF.ES
[-Certified copy b herebydwith rte city GREASE/INDUSPRL WASTE INTERCEPTOR PLANCHECK FEE
❑CertNed copy V(lied with the tlty Inspection division.
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASETRA PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA,270FT. Date RCCEI t#di+•
(This nM
hiv section need 4 completed If permitthe pert V for one
hundred dollars
($100orless.) WATER IdFi1Tl72wNENT/accTR ENERGY FEE Y N
Icertlfythat Nthe performance of the work forwhlch this permit is Issued,
I shall not employ any person in any manner n as to became subject to the WATER SYSTIM/TREATING
Workers Compensation laws of California.Date PAID
0 Z ApplicantZ O NOTICE TO APPLICANT.11,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB._SQn. Date ReCei t#
should bamme.�bect to the Worken'Compemation provisions of the Labor
N Code,you must forthwith comply with such provisions orthls permit shall be TOTAL:
> deemed revoked. BUILDING FE
a5 CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z Ihereby affirm that there is a construction lending agency for the perform- TOTAL:
ELECTRIC FEE
M ane,of the work far which this permit is Issued(Sec.3097,C1v.C.)
U O Lander'.Name - PLUMBING FEE
LL I— Ienaer.Addrea QTY. MECHANICAL PERMIT FE8 MECHANICAL FEE
O W 1 mKifythat i have madthisappliationand statethatsheabove information
1 Is correct.I agree to comply with all city and county ordinances and Mate laws PERMIT ISSUANCE PEE$PAID:
r W relating to building construction,and hereby authonce representatives of this
F— Z city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH. Dale ROCeI f#
— (We)agree to ave,Indemnity an d keep harmleas the City of Cupertino }>
a alnM liabilities,judgments,mstsand expenses which may In anywayaccrue AIRHANDLINGUNITEP010,000CFM) SUBTOTAL:
agafru (d City In consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000CFM) - CONSTRUCTION TAX
Sigmtureofgp pData EXHALE TFIOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS
MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(10,100,000 BTU) Data
material as defined by the Cupertino Municipal Code,Chapter 911 and the Recei t#
tHeahh sad SOMy Code Section 25532(a)2 HEATING UNIT(OVER 100,000 BTU) TOTAL:
RYes ri No
ill the applicant or future,building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISS ATE
which cadt harardous air contaminants as defined by the Bay Area Air
4 Quality Management District? BOILER-COMP OHP OR 100.DOO BTU)
4 Ye. Q No rl9
have read the hazn7i"ousmaterials requirements underChapter 6.95 of BOB,ER-COMP(OV[R 100,000 BTU)
thelfoerstand that If th de building
gdoes not currently
have
a tend,that
�
understand that iftIfy the occupant of to raquiyments tenant that b is not NEW RESIDENTIAL MECH. SQFf.
responsibilityto not the cats of a the requirements which must be not
prior to issuance of a Cenifiate of Ocmpanry. '
Owner or authorised agent Data ISSUED BY �41x't'a•�
TOTAL:
OFFICE COPY