20574 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
v.
Building Project Identification - PIiIWET NO.
Build Ing Address: -
03Re .s E vE as'7-� ��' 2.0574
am.: one: - - A
w era S K - CITY OF CUPERTINO-BUILDING DIVISION
° rami° .Name: ] APPLICATION / PERMIT "
. ( V
6mf �• 'f ur."°:J
'51-5Z. J BUILDING-ELECTRICAL PLUMBING-MECHANICAL CATEGORY CONTROL p
Arc Rect/Engincer: _l Lie No: e
QTY d"B'
Ti
•- UILDI,NCPERMINFO
ILUMD
t ;41 4 ,ELECTRIC EERMCF t � t 'sFEEt,}. -
Address PERMITISSUA E .DO .IY •-
LICF.NSEDCONTRAC R'SDECLARATION
]hereby affirtn lhnllam Bcrosed underprovWons o(Chapter9(commenc APPLIANCES 'ENTIAL JOB DESCRIPTION
Ingwlth Sect1on7000)of DlWaan3o(thea Busineeand Pm(esal...Code,and rey r - -
Ilmnse le In f 11 f endaffLlc.a PANELS
LlmnaaGlam 5"2-3LB - . '(
Date Contractor g�( 11 Ode-
- ARCHITECTSDECLARATION ' - 201-1000 Amps -
re0Z Iundentand my phns ahaBbe used as publicrcmrds OVER 1000 AMPS SQ.F'P.FLOOR AREA S/SQ.FT.
pO
E (/ Licensed Professional SIGN LFCTRI
�<<6LUL OWNER-BUILDER DECLARATION - SPECIA R2C /M -
jt., .7a 1herebyaf@m that Is.exempt from the Contradm's License Law for the
oo following reason.(Section 7001.5,Business and Professions Code:Any city or
OZF' county which requires a permit to commuct,alter,improvq derrodul ormpalr TEMP.M RPO T. -
�y any stvavrc prlorto lb bauanc.,ahoregWrethe applicant(or suchpermitto
L`C fie a signed statement that he h licensed pursuant to the provisions of the POWER D: ES
� n,a Contractor'.License Law(Chapter 9(commencing wkh Section 7000).(Divi- SWB,f,YgNG ELECTRIC VALUATION
the
WWW O si°n3oftheeusinesaand Prmesslma Code)or(hat hebexempttherefromand tP—�q
�6$ the basis for the alleged exemption. Any violation of Section 7031.5 by any OUILETSSWITCHESFIXTURES r J I/ a
O appBcantfor a permit subjects We applicant to a civil penalty of not more than S 0 -
'aFjI,five ndred sowneliors fthepr, NEW RESIDENTIAL ELECTR STOItI TYPE CONSTRUCTION
❑I,as owner l the property,or my employees with wages r thele dole SQ.Fr.
C <. compensation,Busiothe work,ness
and prloal..Cdurehnm intended License
eLaw
t]
sole(Sec. ppy to an
df property
Code:The Contractors Llmnse Law
$ docs noes such Cork imnerofproutgh iswho
nempor imprwethereat,
atsuch 'OCC.GROUI' RES.UNITS
EE
who doeneuchwork himselforthr°ugh hlsownemploydes,provldM lost such
Improvements are not intended oroffered forsale.If,hcwcveq thebuilding or TOTAL: ;I_V
improvement.sold withlnoneyearofcompletiorytheowner-builderwlll have ..
thrturden of proving that he did om build or impmve for Purpose of sale.). QIy, �; 'PLUMBINGPERMIT,'', 1" :'''FEE„ —FLOODZONE APN
LJ I,as owner of the property,am exclusively rontracting with Licensed PERMIT ISSUANCE.ed PcontracoradthapwmfdeMo (S704yBusinaanrofessionsCode:
The Contra cme
apply to an owner m property who ALTER-DRAIN&VENT (EA)
' builds or Improves thereon,and who contracts for such - -
p jects with a ' - .1 '„s,F6E SUMMARY '
mlUlacror(e)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LII am exempt under Sec B &P C Jor lhh,reas°n
•
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N Owner - Date - RECI7I'Tp
WORK MAN COMPENSATION DECLARATION FB(TURES-PER.TRAP SCHOOL TAX Y_ N
❑1 hereby affirm that I have a certificate of consent to opytnwre,ora L- 'd RECEIPT N
3800" teufWorken'C.mpensation Insurance are certified copythereof(Sec. CAS EA.SYSTEM-]INCH OUTLETS PARK FEE Y N
Policy M RECEGAS FA.SYSTEM OVER 4(EA)
17 If
Com any �- � - BUILDDINGING DIVLViSION FE I's
[�Cyfllled copy is hereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR. PLANCHECK FEE
ertifled copy h filed with the city mope ti.n division.
CERTIFICATE OF IX::MPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE ;. SEWER-SANITARY-STORMEA.2001+C. ' Date Recel t#
(Thlaaees.) need nM be complMed if the permit.(°cone hundred tlollars
(4100).rlea3 - WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I aertifynot that In the person
in any m worneer an as to b co a subject
cooed, —
I dose not employ any Laws In any manner eo u to become wbjea to the WATER SYSTEM/TREATING
Workers'n Compenaatlan Laws of Call(omh.Date PAID
PP "
Date Remi t#
� N077CET0 APPLICANT:If,akar making this Certificate of Exemption,you NEW RESIDENTIAL]'LMB. SQ.FT.y
Fshould became subject to the Wmkers''Comperuatlon provhions ofthe Labor - TOTAL:
N Code,you must forthwith comply with such provision orthis pemdt shall be
W G deemed revoked. - BUILDING FEE .D
dCONSTRUCTION LENDING AGENCY SEISMICFEG d
(hereby affirm that there Is a constrncilon lend Ing agency for the perform ELECTRIC FEE _
� Z ance of the work for which this permit is Issued(Sec.3097,Civ.C.) TOTAL:
(„) O Lenders Name - PLUMBING a. •UU
G FEE ,
LL H Lenders Addreas QTY. MkFIANICAL,PERMIT - �FEE�, MECHANICAL FEE
E-
DW l certlfythatl have read thisappllcati°nand antethattheabove Information
C .comet.Iagrreto comply with all city and county ordlnances and state laws PERMIT ISSUANCE FEES PAID:
>. relating to building construction,and herebyauthorize representatives o(this . _
V) city to enter upon theabove-rnentloned property for inspection purpose. ALTERORADDTOMECH. Date ReCeI t#
— ce to uvG Indemnify an tl keep harMem the Ityof Cupertino - P
ag at Bab idea,judgmcntgco and a which may�,anyaay mm AIR HANDLING UNIT 10,000 CFM) SUBTOTAL:
a Imtsaid ityin e. dare ft ng oflM.perret.
. 40.01V
G / AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
nal .o( ppllcant/ a Dae IX}IAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA2'AR OUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haeasmas + HEATING UNIT(T6 l00,mo 81Tn Date Receipt#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Iiealthand Safety Coon Section 25532(.)7 HEATING UNIT(OVER 100,000 BTU)' TOTAL'
❑Yea u No
Willtheapplicint or future building occupant useequlpment ordevice VENTILATION FAN(SINGLE RESID) - ISSUANCE DATE
which emit haeardous air contaminants as defined by the Bay Arca Alr n ■P�
• Quality Management District? BOILER-COMP QHP OR 100,000 BTU) R�f LRL
'TYe. no No
havcmadthehaadOusmate ab requiremcetaunderChapter6.95°1' BOILER-COMP(OVER 100,OOD BTU) u�V l d �](�
the California Health&Safety Code,Sea lore 25505,25533 and 25534. I J IJJI)
understand that if the building does not currently have.teasel,that It Leroy NEWRESIDEMTALMECH.' SQ.ET. - -
responsibility to notify the occupant of the requirements which must be met .6
prior to issuance of a Certificate of Occupancy. Clh/ f`aVpe,llnm
V
Owner or authortred agent Data - -TOrAL: ISSIIEDBY�s �'
k
OFFICECOPY.