19708 0APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
r4 IBuilding Pro'ece Identification PEILMIT NO,
Building Add mss:
P'5 fan LD o I L[ 19708
CITY OF CUPERTINO-BUILDING DIVISION APPIJCATf07MU=AL DAM
c ntractor'aNa LIc.Nw APPLICATION 1 PERMIT
�Auu Fr—E
LIC No: BUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CON YL N��
Architect/Engineer:
LU I QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
IhthSyin7OOO)that fambcen3oftheunder provblmnsofCMmsrodmand ne MPLIANCESRE4DEhTIAL Is-.as-T't " OB DFS SC_ Of J. 1
ingwOh Section forccafDivi-Ion3oHhe Buslneuand ProfesalonsCode,find my `1 ��'j•d-eF�u�7a-Es�s.{^�4�{�.
license isins forceandeffect. PANELS I> Hcx
License Clan Gap
Date Cmntndar
ARCHITECT'S DECLARATION MI-10DUAMPS U
µ❑!rc z I understand my plans shag be used as public records. OVER 1000 AMPS `SQ.FT.FLOOR AREA 5/SQ.FT.
E%U(9 Licensed Professional SIGNS ELECTRICAL
<G Fri
OWNTRBUILDER DECLARATION SPECIAL CB4CN7/MLSC, Iherebyaffirmtexempt frorethe
License Law for the
oo following enaaon.(Section 7031.5,Business and Professions Code:And or
countywhlchrequlresaperrdtromnsirod,alter,improvgdemolish,orrepair TIME.METER OR POLE INST.
anystructure price to its baaance,also requirestheappheznt forsuch permtto
file a signed statement that he is licensed pursuant to the provisions of the POWER DEVICES
5E0
td�+O< aeon3ofthe Busineasand Profesknu Codemthe he bexempt therefrocrand SWNPOOL OL ELECTRIC
E Contractor's License Law(Chapter9(conunencingwith Section 7000)ofDivi-
the basis for the alleged exemption. Any violation of Section 7031.5 by any ^^ -yes
m applio.otfor a Permit subjects theapplicant to a civil penalty of not more than 'V OUTLETSSWITCHESFIKTURE$ S� �
G live hundred delta.(SM. NEW RESIDENTIAL ELFGIR �,pl',
�n ❑L as owner of the property,or my employees with wages as their sole STORIES TYPE CONSTRUCTION
6 compensation,will do the work and the structure is not Intended or offered for
D sale(Sec.7044,Business and Profeadme,Code;The Coniractoes Limrue Law
( $� does not a pply to an owner of property who builds or Improves thereon,and OCC.GROUP RESUNHS
0. who does such work himself orthenagh his own employees,pmvidecithatsuch
Improvement sate not Intended oroffered for sale.I(howeveglhe Wildingw TOTAL: C
improvement b-uld within oneycarofcompletlon,the owner-bullderwill have
th ,r,den of proving that he did not bund or Improve for purpose of sale.). QTy. PLUMBING PERMIT FEE FLOOD ZONE ArN
c6�-QT I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
t Acton to mmtmd the project(Sec.7044,Business and Profe rlons Code:
The Contractors License Law does not apply to an..or of property who ALM-DRAIN kVENT-WATER(EA)
Wilds or Improvesre
thereon, and who contracts for such plojeats with a
911¢Pdor(-)Bcenaed Pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
i it am exempt under Sec. B k P C for this mven
a
OUTSIDE ELL5
Owner Data DRAINS FLOOR,ROOF,AREA,COND, SANITARY Y_ N
WORKMAN COMPENSATION DECLARATION RECEIPT p
C31 hereby affirm that I have a certificate of consent to self-meure,or FIXTURES P PER TRASCI{OOL TAX Y N_
certificate C RECEIPT#
MOO,L.bC.Worker'Campenutlonlvurancemacertlfkd coP)'thereof(Sec. GAS FA SYSITMI INCA OUTLETS
polis Lab C.) PARKFEE Y N
Pdiry p RECEIPT a
Com any GAS EA.SYSTEM-OVFR4(EA)
CeniRed copy is hereby fumished. BUILDING DIVISION FEES
[-]Cenified copy b filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF OEM PTION FROM WORK ERS' GREASETRAP PAID // /�y�re�sa
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200F1' Date Reeel tit 11*4 v
(I).r Lion need not be completed lithe permit b(fir one hundred dollars
(f1W)orless3 WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
Imnot that lnthe paraen nce inan the mnnek foras towhich thbpermit bbo thd'
I shall not employ any person In any manner so as to become subject to the
Workers•Compensation Laws of California.Date WATER SYSh]N/TREATING PAID
-
NOTICE
Z Applicant
_Z O h'OTICETOAPPLice"ot eWorlrmakingthbsationprovisoxsofthe,you NEW RESIDENTIALPLMe. SQFI'. Date Recei t4( SoeM
should bum most
subject to the Worker'such
prountio provisions of the Labor TOTAL:
~ UI Code,you rtwst forthwith comply with such provbbess rrthb permit shall W
LU > deemed revoked. BUILDING FEE .�
CL O CONSTRUCTION LENDING AGENCY SEISMIC FEE L
Iherebyaffirm that there ba coo-troctlon lendingagency for the perform- ELECTRIC FEE (�
O ance of the work for which this permit is neact(Sec.3097,Civ.C.) TOTAL: C
U 1.ender'n Name PLUMBING FEE CIO
LL H Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icetlfythatl have read thbappBotlon and astethatthe above Information a
a bcorrect.I agree to comply with all cityand county ordinances and state laws PERMIT ISSUANCE PEES PAID:
} 03 relating to building mretrodion,and hereby authorize representatives ofthb
F- Z city to enter upon the above-mentioned•property for Inspection purposes, ALTERORADDTOMECH.
(We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Recei tic
V against liabilBin,judgmencs,onstsand expenses which may In any way accrue AIR HANDLING UNIT(to to,"CFM) SUBTOTAL-
MR
inat said City In consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 1 eB00 CEM) CONSTRUCTION TAX
Slgeutu re of ApP"c"m/Contractor Date EXHAUST IIOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haeardous HEATING UNIT(TO 100,WO BTU)
material as dell ned by the Cupertino Municipal Code,Chapter 9.12,and the Date ReceI tM --II
I and Safety Cede Sedion25532(a)7 HFATINGUMT(OVERID0,0009TU) TOTAL- e `O
Y. Ii No
Will the appllram or future Wilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
whichemit applicant air core building
as defined use
the Bay Area Air de
W lily Mawgemcnt D'uMct7 UBOILFR-COMP OTB'OR100,IXO BTU)
4Yes I No
havcreadthe bazarTtnutmaterials mquirerrcntsunder Chapter 6.95of (OVER 10),000 BTU) mo
the Callfe.n liealth&SaletyCode,Sectiov25505,T533and25i34. 1 understand that ifthe bulldingdovxrmcurrentlyhaveatenant,that itismy TIAL MECIL SQ.FF.
rnpomibllity to notify the occupant of th requirements which must be met
prior to� /cfa Ccriifiot of anry.
r rauthwized ager Date
J TOTAL: ISSUED BY:
OFFICE COPY