20034 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALLPOINT PEN ONLY
e Idles Pro ct Identification a - PITM I'NO.
jd Ing Addr, a - - 20034
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d r a V one:
. lr CITY OF CUPERTINO-BUILDING DIVISION p0
Llc•No: APPLICATION / PERMIT
' ,%W Big DING¢ECTRICAL¢UMBINGMECFIANICAL' CATEGORY. CONTROLY
Architect/Engldeer., Etc.No:
- BUILDING PERMIT INFO
•' - ELECTRIC,PERMIT, aGEH• � -
Address: a POMITISSUANCE ,IfQ ❑ F1 ❑
LICF.NSEDCONTRACTOR'S DEC LA RATION
I hereby aflirrnthat l are licensed under provisions of Chapter9(commenc- APPLIANCESRESIDENHAL • BDESCRIPRON
IngwitieSection 7000)o(Dlvislon3oftbe Buslnessand Profeaeom Code,and my
limnxlslnrullfo er(M. PANELS
Llcense��Lic.
Date Contactor La!TO 200 ANTS
-
CHITECPSDECLARATION 101.1000AMPS
p02 lundentand my plans shallW used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
p�Lu O
k Licensed Professional SIGNS FLECTRICAL -
dd 6 OWNER-BUILDER DECLARATION
7 y SPECIALCIRCUIT/MISC
I hereby affirm that l am exempt from the Contractor's Licrow Law for the
pp followleg reason.(Section 7071.5,Business and Professions Code:An d or
0 o ty TEMP.MErIROR POLE INST.
K� county cl�m,nforrequimsa issuaperma,al o equirratheauct,alter, provgdemolbh,ortompair -
q'11 zany almdureprlortaltshat he
llsorcquireslhent to the
provisions
permit e POWER DEVICES -
6 K � file a signer datement that he h l]rensed pulsus.[to the provbiov of the
Comadoes License Law(Chapter,9(oommencingwith Section 7")ofDivi-
"F'30r° aion3o(the Business and Pro(emlosu Code)orNat hebexemp[therefromand SWBr(MING POOL ELECTRIC VALUATION
the bads for the alleged exemption. Any violation of Section 7071.5 by any OUTLETSSWITCHISFIXTIIRFS
- '
0•°
applicant for a permit subjects the applicant to a civil penalty of no rrothan
re
^ Bgg,pungreadoll..(ss0M. .
NGW RESIDENTIAL ELECTRSQ.FT. STORIES
1,as owner of the property,or my employe.with wages as their sole, , TYPE CONSTRUCTION
compenadon,wllldothe work andthe structurebom Intended or offered for
O sale(5er.7044,Business and Professions Code:The Contractors Llcem,Law
,p/ $ doeedotapplhy Loan owner of property who Wilds or improves thereon,and VD
n whodaessuchwork himself°rthmugh hlsovormpl°yen,provided that such � -OCC.GROUP RFS.UNITS
Unproveneenb are not intended oroffered formic.If,however,thebuilding or - TOTAL:
improvement ssold within oneyearofcompldlon,the owner-bullderwlll have , .y,
the*rden of proving that he did not build or 4nprove for purpose of sale.). QTY, '")• -J PLUM BIN&PERMIT FEE � FLOOD ZONE APN•
u L as owner of the property,am exclusively connecting with licensed PERMITISSUANCE
contractors to construct the project(Sec.701,Business and Professions Code: '
The Contractor's Limas Law does art apply to an owner of property who ALTER-DRAIN VENT-WATER(G)
Wilda or improve thereon, and who contacts (or such plojeces with a
my(jactor(s)licensed pursuant to the Contractors License Law. t'FEE SUMMARY
LJ I am exempt under Sec. B&P C for this reason BACK FIAW PROTECT.DEVICE'
DRAINS FLOOR RODF,AREA,COND. SANITARY Y N�
Owner Date -
WORKMAN COMPENSATION DECLARATION RECEIPT gTEX TEXTURES-PER TRAP SCHOOL TAX Y_ N
❑I hereby affirmorkem that 1 have a certl0aee or consent dtfi to sol!-Insure,or RECEET Y
i certiflatex(Warken'Comperuatidnlmuranre ora¢rtlfled ropy thereof(Sec. GAS EA.SYSTEM-1INCA OUTLETS - PARK FEE - Y N
Polis lab C.)
Policy Y GAS-EA.SYSTEM-OVER 4(EA) RIM I=Y'
CO any BUILDING DIVISION FEES
.9Certified copy is hereby fumlehed. GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE,
Certified copy b flied y fu the city Inspection division.
•CERTIFICATE OFEXEMPTION FROM WORKERS' GREASETRAP PAID
` COMPENSATION INSURANCE SEWER-SANITARY-STORM LA.MOFT. Date RCCeI I#
(Thissectlod need not be completed lithe permit Is for orm hundred dollars
(s100)ortem,) WATERHGTER W/VENT/¢FCTR ENERGYFEE Y N
I certify that In the performance of thework forwhich this permit is issued;
1 shall not employ any person In any manner so n to TRSYSTEM/TRrAbroom,subject to the WA ,HNG
Workers'Compensation laws of California. Date PAID
Z NOTICcant
NEW RESIDENTIAL PLh1R._SQ3R Date Recei t#
Z-O NOApplicant
APPLICANT:IL,her making this Certificate of Exemption,you '
should bamme subject to the Workers Compensation provlsimu of the Labor TOTAL:
N Code,you moat forthwith comply with such providonsorthis permitshall be BU N
W deemed revoked. . .
CL
CONSTRUCTION LENDINGAGENCY SEISMIC FEE
I hereby there is a construction lending agency for the perform, - r TOTAL: . . ELECTRIC FEE /9Q
7 Z ance°rtheworkfor which this permit is Issued(Sec.3097,Civ,CL " s+-<-
O O
Lend ere Name - - - PLUMBING FEE
LL F Lamers Aaaress - QTY, MECHANICAL PERMIT FEE MECHANICAL FEE
OW I certRylhat l have read thlsapplicationand elate that theabove information '
1 Is current.I agreeto comply withal]cityand oountyordlnances and elate laws PERMIT ISSUANCE FEES PAID:
>. relating to building comtruction,and hereby authorize representatives of this
F city to enter upon the above-mentioned property for bxspection purposes. ALTER OR ADD TO MECH.
V) Date RCCei f#-
— (We)agree to save,Indemnify an d keep harnaess the City of Cupertino - P _
IablOtlee,judgme b,coeds and expenses which may in any way a AR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
A -/
.gal at old Clty in cons ore o(thc granting of this P It.
RHANDLINC UNIT 10,000CPM) CONSTRUCTION TAX .
Sig ureof Applican 1 tractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
d ; HAZARDOUSMATERIALSDIS 1 SURD
Will the applicant or!atom building oaupantst r orhandlehazardous HEATING UNIT(f0100,0006T11) Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9.11,and the
Ilealth'and Safety Code Sectlon25531(a)? HEATINGUNIT(OVERI00,00011TU) TOTAL:
Fn�
yes, NN. -
�YIIltheapplicantorfutureWildingocevpantuseequipmentordevices VENDLATION FAN(SINGLE RESID) ISPA DATE
which emit hazarduua air contaminants as defined by the Bay Area Air ,C•+'!(J�Vl.�
Quality Mawgement District? BOILER-COMP(311P OR 100,000 BTU) �)
��• 7 Yes �No IJU
haverms Health
. materials tioW 25505, 5533 and 25511.
55 r.1 of ROILER-COMP(OV1I2100,000 BTU)
theersta rd that if ilhbuildiy Code, ctcuSections 25505,ve a tenant,that
�IIIN1' r"
understand that lithe building does nm currently haveatenanq that ltbmy NEW RESIDENTIAL MEGs. SQ.FT.
rap°suibivanoc of a Cche cafe of
ofthancy.' mems which must be rret pV Q rupP„YIRO
'
prior to issuance ofd Certlfkate of Ocdpanry.' � .Y C1- �, 15 '
Ownermaulhorneed agent Data - - ISSUEDBY_�� h
]OTA I.:
OFFICE COPY