20271 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prnect Identification 7 PERMITNO.
BuOding Address: 20271
"1 O^1�a�
�,� r, sr �•Nc� Ra 973-0317 G G I I
weer. one:
jt sore. /JH CITY OF CUPERTINOL BUILDING DIVISION
Contractor's Name: Lit.N. APPLICATION4 PERMIT l O
da u. L E3 BUILDING•ELECTRICALPLUMBINGMECIIANICAL CATECORY f CONTROL#
Architect/Engineer. Lk.No:
QTY ELECTRIC PERMIT, FEE BUILDING PERMIT INFO
Add. 6Q�•k PERFIITISSUANCE 1:1 [ILICENSED CONTRA OR'S DECLARATION
ly I hereby affirm that l am licensed under provhlons of Chapter 9(rommeno APPLIANCES-RESIDENTIAL. JOB DPSC=ON
ingwltb Sed1on7000)of Dlvialon 3 afthe Buaines,and ProfesslonaCafe,and my
license is In full force and effect. PANELS /1 `Ts lr�
License Clam Lk.# dAxl v
Date Contraor 1SS
ARCHITECTS DECLARATION 201-1000 AMTS
Q
Z I understand my places*hall be used as public rzumda OVER 1000 AMPS SQ.Fr.FLOOR AREA S/SQ.FT.
�COq
(u Licensed Professional - SIGNS ELECTRICAL
< OWNER-BUILDER DECLARATION N
res a fBmromSPFCIALCIACT/MLSC
Z.
Thereby anthatlam exemptlthe Contractor's Licence Law far the
O Z
o following reason.(Section 7031.5,Business and Professions Code:Any city or
r� countywhkh requlmsapertNtmmvaWct,alter,lmpmve,demoWh,orrepair TEMP.METFRORPOLEINST.
d
anystruure,pdor to its matance,also reyulds theapplicant(orsuch permit to POWER DEVICES
( file a signed auxurnent that h is licensed pursuant to the provisions of the
Contractor'sLicense Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELEC
TRK
BOJ sion 3 ofthe Business and Profe®bv Code)or that he is exempttberefromand A ON
......]]7]]7 the NA,for the alleged exemption. Any violation of Section 70315 by any OUILEISSWIICHESFIXil)R
applicant fora permit subjects the applicantto a civil penaky of ect more than
live�sandred dollars($500).
I,as owner of the property, NEW RESIDENTIAL ELECTR B TYPE CONSTRUCTION
�n p perry,or my employers with wages as their sate
compenaaHon,will doth work and the structure b not Intended or offered for
Osale(Sec.7044,Business and Professions Code:The Contractors License Law
$ does not apply to an owner of property who builds or improves thereon,and EEAU
C.GROUP RIS.UNrfS who does such work himself orthrough Ms own employees,provided that such
Improvements arc not Intended orof(cred forsale.If,however,thebuilding or TOT
Improvement is sold within oneyear olcompldloq th owner-buliderwlll have
ttnIurden of proving that he did not build or improve for purpose of sale.), QTY, PLUMBING PFEE
LJ L as owner of the ro ZONE APN
p perty,am exd4,Busi Business
Pro with Ilcenacd PERMIT ISSUANCE 00
contractors to construct the project(Sec.7014,Business and Professions Code:
The Contmctar'a License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WA '[U)"
Wilda or Impon
Improves there ,and who contracts for such projects with a
c,XtPcchd(a)licensed pursuant to the Contractor.License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
QI am exempt under Sec B&P C for this reason
DRAINS-FLOOR,ROOF,AREA,COND. SANITARY Y N
Owner Date O RECEIPT#
WORKWIANCOMPENSATIONDECLARATION 17%TS]RF.S PER TRAP SCHOOL TAX 'Y N_
❑l hereby affirm that I have o lmum to of consent m apytheure,ora RECEIPT'N
'recti(Ica/eat Workere'Comperwatlonlruurance ora certified ropythercof(Sec. GAS EA.SYSTEM-1 INCA OUTLET'S PARK FE Y ' N
Pour,# GAS EA.SYSTEM-OVER 4(EA) DING DI N
Cam any BUILDING DIVISION FEES
�Certl(lei copy h hereby filed
the city
GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy h filed with the city inspection division.
'CERTIFICATE OF EXEM PTION FROM WO RKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date RCCM t#
phis section need not h completed Bth permit h(Drone hundred dollars,
($100)mIces.)
thatth WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
at In the performance of the work(arwch this permit is Issued,
1 shall not employ any person In any manner w w to become subject to the WATER SYSTEM/TREATING -
Workcrs'Compensation Laws of California. Date PAID "-
O Z Applicant NEW RESIDENTIAL PLMB. SQ.Fr. Date Reeel t#
Z O NOTICETO come..ICt to the
eller making thio Compensation
provisions
Exemption,you
Fsbouldoumus eurthwit tcomplyWorit compvuetmn pmvhioruofine Laborbe TOTAL:
W N Codddre raked.forthwith comply with such provhion or this permit shall be
seemed revoked. BUILDING ••E
W 72- oo CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Iberebyatfirm that there Is a construction lending agency for the pedord, ELECTRIC FEE ~
Z ance of the work(car which this permit h Wued(See.3097,Civ.C.) TOTAL: d
O O lender's Name - PLUMBING FEE uo
LL 1- Lender's Addron QTY. .MECHANICAL PERMIT FEE, MECHANICAL FEE
O W Iredifythai l have read thlsapplintionand stetthat lheabove Information
hroing wbgreeto comtrudidhall dftyandhereb authorize
representatives
gate
softhilaws PFRMITISSUANCE FEESf(A
} W rclatoenteruponthe
e above-mentioned property
authorizercprcsenpurposofrials 71�fyai
Z city Wr)aree to the,indenedly an
properlyfor
as the Cit purposes. ALTER OR ADD TO MECH.
(We)agree to save,Indcmntty an d keep harMen the City of Cupertino to Reeei t# Tex ry
V agaWtllabllltles,judgments,coatsand expenaeswhlch may inanywayaccrue AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL:
agalnatsald City in sequence of the granting of this permit.
�fp y��o �4Q MRHANDTINGUNIT(OVER I0,000CF) CONSTRUCTION TAX
SignatureofAEplllnht/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wllltheappllcant or future building occupant store or handle hazardous HEATING UNIT(TO 1fID,000 BTU) Date Recei I# Y'
material as defined by the Cupertino Municipal Code,Chapter 9.1;and the
I Tealth and Safety Cader�Section 24532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL'
F1Yes u No
—Will the applicant or future building occupant use equipment or devims VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which a Management
airrict? amsn defined by the gay Arca Air
Quality Management Distdct7 BOILER-COMP pIm OR 100,000 BTU)
q Yes No
have read the bazar ous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) 0
the California Health&Safety Code,Section 25505,25533 and 25534.1 - �- 194 77
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECIi, SQ.Fr.
responslbllityto nalfy the occupant of the mqulrcments which must be and .S�
'pdortol uanceo(a CeAificateofOtt panty. --Lr E# �tIOP.t#110
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE COPY
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