20582 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Address: '" 2058 2
11hof94 u sU 2; - -
.^ one: APPLICA 11UN 5U61,111 IALA IL
CITY 0 F CUPERTINO-BUILDING DIVISION / �C
o-a r.Name: Lm. m - APPLICATION / PERMIT 6
K 5rio RIA n4
BUILDINGELECTRICALI'LUMBINGMECkUMCAL CATEGORY CONTROLp
ArcM1itect/Engineer. Llc No:
FEE "BUILDING PERMIT.INFO
- Q1Y 1.'+' i�-}ELECT2IGPERMITy - 1'` t - • ,I
Address: PERMITISSUANCE .+
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am leased under provisions of Chapter9(commare APPLIANCESRESID(SITIAL - ]OB DESCRIPTION
IngwithSe ion7000)of Dlvtslon3ofthe Buslnessand Pm one Code,andmy
license Is In fu}kfa yyi�d effect. ..(( /'� PANELS
-
it...
.LvLk N !TS•7-
Date Contractor I J ,
ARCHITECT'S DECLARATION 201-I DOO AMPS v
pppp++0 C20 I understand my plans shall be used as public records. - OVERI000AMPS SQ.IT.FLOOR AREA $/SQ.FT.
E (Cj .Licensed Professional - SIGNSF ECTRICA
<<�6 OWNER-BUILDER DECLARATION - SPECIA CM
'7s. 'L IherebyafBrm that l am exempt fromthe Contracbm's License law(orthe
qq following reason.(Section 70715,Buidni s and Professions Code:Any city or
� sy co.tywhlchrequbeaxpemaitt.co.tmct,ithegimprove,demoRsh,orrepalr IFMP.M LEIN
gq' ❑❑ anystructure priorto Its issuance,also requirestheappllcant forsuch perMtto POWERD
[y5 file a signed statement that he is;Ilmnsed pursuant to the pmvBdom of the
%3µ Contractors License Law(Chapler9(mmmencingwith Section 7000)of Di vi- '
4 COs SWIdMING
tlon3 oftha Business and PrefemvioCede)aithat he bexempt therefromand ELECTT(IC VALUATION
6 5 the basis for the alleged'exemptlon. Any violation of Section 7031.5 by any OUTLETSSWITC FIXTURES
applicant for o permit subjects the applicant to a civil penalty of not more than
five hundred dollars($500).
I,as owner of thea NEW RESIDENTIAL ELECTR SQ.FT. STOIU PS TYPE CONSTRUCTION
prop rty,or my employees with wages as their sole
�7a rompc...Hog will dothework,and thestructure isnot intended or offered for -
O
it(Sec.7014 Business and Professions Code:The Contractors License law
S does not apply to an owner of property who builds or improves thereon,and - .00C,CROUP RfS.UNITS
who does such work himself or through his own employees,provided that such
improvements are not Intended oroffered forsale.If,however,thebullding or TOTAL: -
Improvementissoldwithinoneyearofcompldion,theowner- ilderwill have -
t rden of proving that he did not build or improve for purpose ofsals,). QTy,' ''�'•' 'PLUMBING,PERMIT'' I'„ 'FEE' `
� + FLOOD ZONE APN
LJ L as owner tr the property,am.7044 exclusively Busi Business
and Proing with licensed PERMIT ISSUANCE
rc
contractors to construct the projM(Sec.7014 Business and Professions Code:
The Contactor.License Law does not apply to an owner of property who ALTER-DRAIN&VENT- IR(
-WATER , f
bu Bda or improves theme., and who contracts for such ptojectx with a ..
ador(s)hcensed pursuant to the Contractor'.License Law. BACK FLOW PROTECT.DEVICE: F' 'FEESUMMARY
I am exempt under Sec. B &P C'for thin reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N '
Owner- Date A re or a RECEIPT N
WORKMAN COMPENSATION DECLARATION; FIXTURES.PER TRAP SCHOOL TAX Y N
QI hereby affirm that I have o mrtiBate of consent to opytneu RECEIPT N
mrt0fleste,Lab of Workers Cemperwtlonlmuance ma certified ropytbereof(Sec. GAS EA.SYSTEM-1 INC4 OUTLETS PARK FEE Y N
3800,Lab C.I'
Pollryp GAS EA.SYSTEM-OVER — RFOQITp
Com BUILDING DIVISION FEES
CenlOed copy is herebydwith the city GREASE/1NDUSTRL WASTE INTERCEPTOR PLANC14ECK FEE -
xd
�CedRedmpyVflled with the city Inspection division.
CERTIFICATE OF EitEPTION FROM WO R K ERR' GREASETRAP PAID
COMPENSATION INSURANCE' SEWER-SANITARY-STORM EA.200I+C. Date Recei t#
Qhis section need not be completed tithe permit is forooe hundred dollars P
(4100) .) WATER HEATER W/VENT/ELfLTR ENERGYFEE 'Y - N
I certrtlty ifytthat In the performance of the work forwhich this permit Is luued,
I shall not employ any person In any manner se as to become subject to the WATER SYSTEM/TREATING
Workers'Compereation laws of California. Date PAID
•Z Z Applicant NEW RFSIDENTIALPLMB. SQ.FT. Date` Remi t#
NOTICE TO APPLICANT:It,after making this Certificate of Exemption,you -
shouldbecomembpdtotheWorkers'Compensation provisimu of the Labor �Nss TOTAL:
W Code,you must forthwith comply with such provisions or this permit shall be ��V
W O deemed revoked. BUILD -E
jL CONSTRUCTION LENDING AGENCY + SEISMIC FEE
I hereby affirm that there bi a construction lending agency for the perform- T ELECTRIC FEE
Z ance of the work for which this permit is issued(See.3097,Civ.C) TOTAL: IVY `
V O I.ender.Name PLUMBING FEE 0
LL I— iaeder.Address QTY. MECHANICAL PERMIT 't ,FEE, MECHANICAL FEE
O W
UI cortifythat l have read thisappuation and.tatethatthe above information .,
0. Extorted.I dgme to comply with all city and county'ordinances and state laws - PERMIT ISSUANCE. FEES PAID:
� N relating to building construction,and hereby authorize representa0ves ofthis ,
Hcity to enter upon the abovcmentbnM property for inspection purposes. AL7IRORADDTOMECH.
Z (We)agree to ave,indemnify an d keep harmless the City of Cupertino - Date Receipt#
V •against liabilities,judgments,eomand expenses which may In any wayaccme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:afst
Inst said City
[Lin el6iquence of the granting of this permit AIR HANDLING UNIT(OVER I utiocitho CONSTRUCTION TAX
SlgnatiidpfAppliant/ContredorDate EXHAUST HOOD(W/DUC l' CONSTRUCTION TAX PAID:
HAZA R DOUS MATE ALS DISCLOS
Will the applla nt or future bu llding occu pa nt store or hand Is hazardiva HFATING UNIT(TO 100,000 BTU) DateRecel t#
material as defined by the Cupertino Municipal Code,Chapter 9.IZ and the - -
Ile❑cult.rd Safely Code Sacioon25532(a)? HEATING UNIT(OVER 100,000 B'rLB TOTAL:-
Yes
- Will the applicant or future build ing«m pant usequlpment or devices VENTILATION FAN(SINGLE RESID) ISSUpygR1 TE
mi ,-
whichet hazanloueair contaminants an de0ned by the Bay Area Air - "
Quality Management District? BOILER-COMP(31 I'OR 100,000 BTU)
Ihave lead the haza'raousomaterials requirements underChapter6.95of BOILER-COMP(OVIR100,BOB BTU) `in 1. '( IJJU
the California Health&Safety Code,Sections 75505,75533 and 25534.I
understand that if the building don not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. - ps .a
rasp IbiBtym natlfy the bavpan[of the requirements which must be met Cit],of,`,B(IBI IIIIQ '
pr t Iasuanceoff;CciEfatcof Occupancy. /per
Owner,41lithorimd agent ate ISSUED BY; H () ✓C(_
TOTAL:
OFFICE OOPY