23472 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: (�I 3472
z� a ei.
wnen one:
A A
an,e " CITY OF CUPERTINO-BUILDING DIVISION
ontractor's Name: Lic.N. APPLICATION I PERMIT 2
012 W G BU[LDINGQ,ECTRICAI PLUMBINGMECHAMCAL CATEGORY CONTROL#
rch
AIcer/ ginner. Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCF ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby d.7000) fDim.i ofChapmr9(mmmenc- APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwah 't1an9000)of DlWslon3o(tM1e Buslneasand Pro(esslonsCode,and my
license is In full f and effect' PANELS
License Class_ Lk.# y`Z.3 i/ G G 4A'r{, s;>•
Date_'j� Catered. i eeA��.a.
—UP TO 200AMI!q
ARCHITECTS DECLARATi9111-1000 AMPS
CX I understand my plzru shall be used as public records. OVERIODOAMPS — 'i > y Fr�FIsQQR AREA $/SQ.FT.
Ft od`j Licensed Professional SIGNS ELECTRICAL ,� �� _ �_ OOtltl\\VVI'
6 c Om WNER-BUILDER DECLARATION SPECIALCIiCUIT/MISC t t u
Ihcmbyaf@m that l am exempt frothe Contractor's License Law for the
Z EE R
O following reason.(Section 7m1.5,Business and Professions Code:Any city or Z
O Z t.8 TEMP.METER OR POLE INST.
Kin cnystmm pr arreltsismdte,alsomct,alstheaplimntfrsuch,orretto
q �.� any structuretatement that he Is hunseulresthant to the rnialom of to POWER DEVICES
t'5 O file a signed statement that he t licensed pursuant to the tion 7000) of the
Q6 roC Cantneors License Gov(Chapter9(mmmentlng with Section 7000)of Dlvl- SWUrtMINGP LELECTRIC
�0� s1on3.Rhe Business and ProfesslonsCode)orthathebsexemptlherefromand VALUATION 00
the basis for the alleged exemption. Any violation of Section 7031Z by any s..�
�< applicant fees permit subjectsthe applicant to a cavil penalty of not morcthan OUTLETS -FIXTURES S .Z �, a
^�^�R flue hundred dolWs($SWI. NEW RESIDENTIAL ELECTR
p 7 I,as owner of the property,or my employees with wages as their sole �'�' STORIES TYPE CONSTRUCTION
compensation,willdothe work andthe structure is not Intended or offered for
p sale(Scc.7066,Busincss.eJ Professloru Code:Tbe Conhadoes License Law
r3$ does not apply to an owner of property who Wilds or improves thereon,and OCGGROIIP RFS.UNITS
who does such work himself or through his own employees,provided that such
improvements are not Intended oroffered for sale.1(howeveq the W ildleg or TOTAL:
ImprovementVsoldwithin.neyearofcompldtb theowner-builderwfli�ve
ttrwpurdenofproving that he did net Wild or Improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE pLOOD 7pNrp ApN
U I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCEcontractorsto condmd the pmject(Sec 7014,Business and Pro/es,ioos Code: '
The Contractor's License Law does not apply to an..or d property who ALTER-DRAIN&VENT-WATER(EN
Wilds or Imon
proves there , and who contracts for such Imajects with a
cpgactdr(s)licensed pursuant to the Contractor'sLicense Law. BAER FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B&P C for this reason
Owner Date DRAINS.FLOOR ROOF,AREA,GOND. SANITARY Y N
WOR KhJAN COMPENSATION DECLARATION RECEIPT#
JI hereby affirm that 1 have a certificate of consent to self-insom,re a FD(TURFS PER TRAPSCHOOL TAX Y N
udiftmte of Workers'Compev.tionlrourance or a certified mpythemof(Sec. RECENT#
3800,Laab C.)N/�/�/t 7I s nj GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y_ N_
poli # V f• a RECEEPT#
Coany (y 6'J/�'� GAS EA.SYSTEM-0OVER BUILDING DIVISION FEES
Certited copy Ls herebytumbhe . CREASE/INDUSrRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy V tiled with the city Inspection,dlvislon.
CERTIFICATE OF FXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Thiasectlonneed notbec.mpletei lithe permit beforone hundred dollars SEWEILSANTTARY-STORM EA.900FF. Date Recei t#
(81 W)oifyth WATER HEATER W/VENT/ELECTR ENERGY FEE Y N—
I
employ
an person
In an the rnerworso as to b comhis esubjrmite Issued, —
I shall not employ any Lam In any manner m u to Wmrre subject to the WATER 5Y67EM/TREATING
Worken'CompensaOon Laws of California. Date PAID
O Z Applicant
Z O NOTICE TO APPLICANT:If,after making l his Certificate of Exemption,you NEW RESIDENTIAL PIMB.__SQFL Date Recei t#
should become subject to the Workers'Comperoation provisions of the Labor~ TOTAL:W Code,you most comply with such provision,orthis permit shall be
W > deemed revoked. BUILDING FEE
(L o CONSTRUCTION LENDING AGENCY SEISMIC FEE
= Z I herebyafflrrnthat there B.comtmction lendingagenq forthe perform ELECTRIC FEE
anceof the work for which this permit Is issued(Sec.3097,Civ.C.) Torwe;
U O Lender's Name
PLUMBING FEE
LL F Lenders wddnss QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertify that l have read thisappllcationand statethattheabove Information
1 uouroct.l agree to comply with all city and county ordinances and date lam PERMIT ISSUANCE FEES PAID:
>. (L to Wilding consuudlon,and hereby authrx zc representative,of this
H Z city to enter upon the above-mentioned property for Inspection purpoxn. ALTERORADDTOMECH.
(We)agree to save,Indecently an it keep harmless the City of Cupertino Date Receipt#
against liabilities,' dgments,costsand expenses which may in anywayaceme AIR HANDLING UNIT(to 10,000 CFM) SUBTOTAL-
agalnst said CiyrV.onaegyptm.(the graining of this permit.
/y/ ///77-0" � _rs/^9a� AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Sigruturc plica /Contractor Dsate ` EXHAUS'T HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theappllcant orfuture Wilding occupant store or handle hazardous HEATING UNIT(TO 110,000 BTU) Date
material as defined by the Cupertino Municipal Code,Chapter 9.19,and the Re:ei
Healthand Safety Cod Sedton9.553](a)7 HEATING UNIT(OVER 100,000 BTU) TO
Ye,
Will the applicant or tore Wilding occupant useequipment ordevices VENTILATION FAN(SINGLERESID) ISSUANCE DATE
which emlt hazardous air contardnanh as defined by the Bay Area Air L�
Quality Management DsMcti BOILER-COMP QHPOR 100,0W BTU) F+-
4Y;s4'i
have read the haza ousmaterlals requirements under Chapter 6.95 of BOILER-COMP(OVER 100,ON BTU)
the Gldomh Health&Safety Coda Sectione 25505,25533 and 9:534.I PEAR 31
understand that rosily
the buildingductnot a currentlyhavetenant,that it is my NEW RESIDGMIAL MECH. S'Q.PT. V 7oc )
responsibility
understand
that if theb it ing occupant of the have whichmast beset 1 l//�`�`\+,\�
p or�opu ceofaCertificateofOcc�p,ncy. CITY QMK 3 3/-9Z t Ur
�r r or authoriad agent Date ISSUED BK7M
TOTAL: CCC..."'�rt1
OFFICE COPY