19767 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES =USE BALL POINT PEN ONLY
�1OeBuilding ProM Identification POWT NO.
e.laingL/V9767
st.remer.NamnAPPLICAToe. CITY OF CUPERTINO-BUILDING DIVISION
c naoYaName: Lx.N APPLICATION / PERMIT L
BIRLDINGE].ECIRICAL-PLUMBING-MECHANICAL CATEGORY CONTROL
A Bea/Engin¢r.' Lb. o:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. PERVTISSUANCE ❑ ❑ X ❑
LICENSED CONTRACTOR'S DECLARATION
Ilemby affirmthat B=3of eBur vhd¢urof h pter9(mmmen AI'I'[IANCESRFSTDEM7AL JOB D N
Inersel i. 7000)o(Dlvlalon3o(megurroaand Prolnrons Code,and rrry
Ikenm ism b a cies.S, PANELSIfte 1,�,� {If
Dat Cb: Glc tr.m.r <<f� I l U -"l V
Date Contractor I
ARCHI'FECPS DECLARATION 201"1000AMPS
O I urdermaM my plats shall be used as public m ords OVER 1000 AMPS SQ.FI.FLOOR AREA $/SQ.FT.
<�j Lkxraed Professional SIGNS ELECTRICAL
� .OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MLSC
zt-. ?s IherebyafRrmthatlamexempt fromtheConradoe.Ll¢rselawfmm.
(olkwing reason.(Sealon7m]S,Buainm ant Pmfmlons Code,Arydyor TEMP.METER OR POLE AST.
muntywhc rein apemdttomvtruMt ter,lmpmve,demolbh,ormplr
��ee any.tmdum piformltl Lssuancgslso iequdnmeappBornt for ouch permit to POWER DEVICES
rG 5 file a signed statement that he is B¢need pursuant to the provisions of the
2 O {� Cmtracmrs Lieeme Law(Chapmr9(coRmendng with Stolon 7000)of Dlvl-
F,P4 don3ofthe Budnmand Profen mCode)orthxhebexemptthmfmmand SWdSU9NG POOL ELECTRIC
VALUATION
K'•]] the inch for the alleged exemption. My violation of SMbn 70315 by any
�A appH.t fora permt.ubjeets the applicant to a dvll penalty dnot mom than -��" Tr FtFT"'FLCfI1Rt"'
R nwndredddhm(S.S00). NEWRIDDENTT ELFCTR
e
Lf I,as owner of the property,or my employewith wages as theft sole SQA' STORIES =CONSTRUCTION
mmpersatte ,wW do the work,and the weds.isrant Intended or offend for
❑ vie(Sec 70K Business and Pmfabns Code The Contractors Lice.law
[�$g does not a pply to an owner of property who builds or improves IhemoR and OCC.GROUP RFS UNITS
doe such work himself m through his own employees,provided that such
improvements am not intended oroffered for sale.IL however,the building or as, TOTAL:
improvement?andelwithinon yearofcornplebntheownerbullderwllllove
t I,rdose eo of provingthad he did not build orimpmee for purpofsale.). QTY. PLUMBING PER FEE
a.owner of the property,am eacbrsely mntracting with Licensed HOOD ZONE APN
contractors to com4ud the project(Sec 70K Business and Prdmbm Code: PERMIT ISSUANCE /
The Co. does Lion.Law does not apply to an owner d property who
builds or Improve thereon, and wlu mmnats for such plokcb wed• AETEA"DRAA WENT-WA
�W(aaMpll
or(s)B¢vd puissant to the Contraads Liaise Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B k P C for this noon
OwnerDate D DRAINS FLOOR,ROOF,AREA,ODND. SANfIARY Y_ N_
RFLIDxT
WORKMAN COMPENSATION DECLARATION FIXTUItFSPERTRAP SCHOOL TAX Y_ N_
` IyOy1I hereby affirm that 1 have a certificate of consent to self-bsum,era gEc=g
¢d111ote afWarken'Compeneatlonlwran¢ora¢rWfed ropy themo(f$ec. GAS FA SYSTENCI INC-4 OUTLETS PARKFEE Y N
3800,Iab CJ e^JO!)1 RECEIPIY
Tolley a CAS FA.SYSITM-OVER 4(EA)
Co nv BUILDING DIVISION FEES
Certified copy ion mbyth the ed. GREASE/INDUSTIL WASTE INTERCEPTOR PLANCHECK FEE
CertNed ropy is filed with tint city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRN' PAID
COMPENSATION NSURANCE gEWER-SANITARY-STORM EA. . Date RCmi tp
(I'hlssedbn need not be completed If the pemJt b foroee hundred dollars
a10o)¢les.) WATERITEA=W/V /ETECIR - ENERGY FEE Y_ N
I¢notthat in the person n¢ofthewoekfolwhichthispermitisisothe
I slu0 not employ any Lxwx f any munnei at se to become subject to the WATER SYSTEM/TRFATINC
Worken'Compensetbn Lsys of Gllfmnia.Date PAID
O Z Applicant m
NEW RDENIIALPLMEL SQFr. Date Recel t#
Z 0 1VOT10ETO APPLICANT:if,after nukingthUCe&l teof Faemp(Ion,you
F y should bernme subject to the workers Compensation povisbnsof the Labor TOTAL:
Code,you nu at forth uh avnply wlthsuch provblansormis pemJt shall be_ BUILDING FEE
W _ deemed rooked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Ihereby af(Irr"Eut them is.mrutmalon lendingagerey for the perforin ELECTRIC FEE
Z arm.(the work whkh th6 permit is Weed 6ec 3097,Civ.C.) T��"
U O Lender's Naim PLUMBING FEE D
LLI— Iemier.Adanese QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I certify that l have mad thbappOntbn and nbo
atethatthe aveon
lnfcmmxl
a isourca.l agreetocomplywith addty and muntyondbunoetand rate laws PERMIT ISSUANCE FEES PAID:
} N relating to building corotmalm.nd herebyauthorlae representative of this cityto enterupon the above-mentioned forImion ALTER OR ADD TO MECH.
~ ? (We)agree to uvq IndemN(y an d keep turmlm the City of Cupartiw Date Recd tit
V against liabilities,Pdgmew,aarsand expenses whldi may in anywayacerue AIR HANDING UNIT(170 10,000 CFM) SUBTOTAL:
against said CB'y lyn�rnsryuerio/e (tine gaming hl.permit. AIR HANDLING UNpr(OVER I0,=CFM) CONSTRUCTIONTAX
NSA/ Xy"+� M We CONSTRUCTION TAX PAID:
p; Mum of APIA m ' Date EXHAUST I-IOOD(W/OLIGO
HAZARDOUS MATERIALS DISCLOSURE '
Will the applitam orfuture building oaopnt store or handle havardous HEATING UNIT(-IO 100,000 BTU) Date Recel t#
material as deBnd by the Cupertino Municipal Cod,Chapter 9.1x,and the
Ekalth and Safety Code S Wn 25532(.)7 HEATING UNIT(OVER IODXM BTU) TOTAL:
❑Ye No
Wllltheapplloritm utum budding aapant use equipment mdevicn VFNTILAFION FAN(SINGLE REBID) ISSUANCE DATE
which emit hamndau air contaminants as dedm-d by the Bay Area Air PAID
Quality Management District? BORER-COMP OHP OR I00,0(D BTU)
Yes
No
+ Wane moa men ons materials requirements under Chapter G95 of BOaFRmMP rovFR I00,0008TI) ll 199U
.41
the C.filamla Heallh&Safdy Cade,Sectbns755W,x5533andx5SM. I 11'I�'I l{ N U I99V
understand that i l me Wilding don not mmently have a tenant,that It b my NEW RESIDENTIAL MFl]i. SQFI ,
responsibility to notify the oavpm of the requirements which nueu be met (s'�s�
prbrblsuarceof.certdlateof0¢vpmy. yl.) of r1�11fxi�ert1j.Ra
Owner or authorlmd agent Date ISSl/ED BY: ' s/ µVEL
TOTAL
OFFICE COPY