23910 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY .
Building Project Identification PERMIT NO.
Building Address: n n O
2 / 79 > 7-E,,-, E Okf G J
nerdName: one: APPLICATION SUBMI I I A
a-n k f—�lti S CITY OF CUPERTINOQBUILDING DIVISION /' ��
. e°ntraeo .Name: Lie.No: APPLICATION I C PERMIT c( —q
rEl�coDPLInG 5P£c"4LCfTT IVC '""?) 'J BUIDINGE.ECTRICAL-PLUMBING-MECH min L CATEGORY CONTROL#
/
Architect/Engineer. Lk.Na
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: I'EtMITI55UANCE BLOC ELECE PLUMB Mfs�ki
® Y y
LICENSED CONTR sed under provisions
APPUANCES-RESIDENTIAL JOB
Ihth Sedion7GOD)o(Di lken3ofthe usinemand Pre Cssionshapter 9de,and y JOB DFSCRI'TIO— N--
ingwltI Infun 7000)of Dleflect (the BupnewandPro(ewloneCade,and my
Ilcenw is In full( and deflect PANELS
PANEIS �'at' `
DateCless 7_Lk.N� W
Date J.. 7_29ContactorUP TO 2M AMPS
ARCHITECPS DECLARATION 201-IWOAMPS
AZO I understand my plamahall be used as public record# OVER IODO AMPS �7®RI FA $/SQ.Fr.
OO Licensed Professional - - SIGNS ELECTRICAL WAV,
6 OWNER-BUILDER DECLARATION SPECIALCIRCIRT/MLSC
Zf�, I hereby affirm that l am exempt from the Contractor's License Law for the ER
pp p following reason.election 70315,Business and Professions Cade:Any city or
O Z s. county IIINP.MEfIlt ORIOLE IN ST.
FO aRystm whichuiresa permitt abo rquimstheaprovntforsth,orrepair /Z
any atrocturc statement
Wt he is licensed
pursuant t the forsuwas of It a POWER Dg17�q TE Gr
(Ile a signed patement that he t mrensed pursuant to the proWaios of the �
tc Contractor's License Law(Chapter9(mnurencingwith Section 7000)of DIA- -
3 O�A SWB.Sh11NG POOL ELECTRIC
s the basis
fo the all fie d exemption. Any violation
of exempt therefrom and VALUATION
appthebashfor theallegedexemthe applicant
Anyyt tolacivi o(nalt on nce,re reany [77LE•ISSW[•fCFIESF7X7VRFS
�� five hundred dollarstaubjemtheappllcanttoacivll penalty o(not morethan ` V O�
five owndoler
of the
NEW RE57DENTIALELECTR_SQ.FT. STORIES TYPE CONSTRUCTION
�n a as owner ll the property,or my employees with wages all their sole
Ocompensation,w01 clothe work rndthe structure went Contractor or coffered for
sale(Sec.apply
to show andf property
Code:The Contractors LicenseLaw
S$ does not apply loan owner of ywho Wilds orlmproovide that and OCC.CROUP RES,UNITS
who does
rversawork himself nded oroffehis own employees, eethe uildisuch
Improvement arenot intended oro(fered for wed,If,however,thebulldingor T
improvement twld withinoneyearofcompletloq theowner-W Iderwlllhave
tl r� jrdeo of proving that he did not baud or improve for purpose of sale.). QTY PLUMBING PERMIT FEE
LI L as owner of the property,am exclusively contracting with Iice sed FLOOD ZONE APN
rontnRon to mrutmctthe project(See 7064,
..and Prxfewloru Code: PERMIT ISSUANCE
The Contractor's License Taw does reapply to an owner of property who AL.I.R DRAIN k VENT WATER
[FA)
Wild. or Improves thaeoM comments+rad who comments for such p(ojewith a
cgBtractor(a)Bmnsed pursuant to the Contractor's License Law. - FEE SUMMARY
LJ 1 am exempt under See. B 4 P C for this rcuon BACK FLAW PROTECT.DEVICE
OUTSIDE FEES
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N_
. Owner Date RECEIPTX
WORKMAN COMPENSATION DECLARATION PER TRAP SCIfOOL TA% Y N
❑1 he affirm that I have o certificate of convent in copy M
certificate of Workers'Compesatlonlwv
unceon certified py thereoeco ora RECEIPT(Sec. I
GAS EA.SYSTEM-1 INCAOUTLMS PARK FEE Y N
3X00,GbCJ
PaNn
- RECEIPT
y GAS FA.gYSTM-OVER4(EA) _ BUILDING DIVISION
ISION FEECryCertdcS❑ EPTORCertified copy t Elm with the sty inspection division. GREASE/WDUSTRL WASTE INTERCPLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SAFIITAAY STORM EA 200FT Date Revel IM
(This section need not be completed lithe permit t forms hundred dollars
(5100)orfy that
WATER HEATER W/VE4.E./E,ETR ENERGY FEE Y N
I certify that t the performance of thewask for which this permit c blued,
I Wham not employ any person N any manner at w to become subject to the WATER SYSTEM/.TREATING
Worken'Compenwtbn Laws o(Gllfomt.Data PAID
Z NOTlicant
ICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.FT. Date Recel t#
should became subject to the Workers'Compewation provbios of the Labor TOTA :
tll Code,you moat forthwith comply with such provtlow or this permit shall be
Ill > deemed revoked. -
CONSTRUCTION LENDING AGENCY SEISMIC FEE
Co-
0. B Ihercbyafflrm that there t a construction lending agency for the perform- T IIA ELECTRIC FEE
M Z arm of the workfor which this permit is Issued(Sec.309],CIv.C.) V✓
UO lander'.Name PLUMBING FEE
LL F Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icertilythatlhavereadtldnappmcatio...daatethatthaaboveinf°ma0°n
C Ls cormet.I agree to comply with aB city and runty ordinanasand pate laws PERMIT ISSUANCE FEES PAID:
�. N rem0ng to building coaatroction,and hereby authorize representatives alibis
I-. Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH. Date ReceiptA
(We)agree to save,Indemnify an d keep harmless the City of Cupertino -
agalmtltb01108s dgment,metsand expenses which may In anywayacaue AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL:
.gal w1aG consequence of the granting of this permit.
� AIR HANDLING UNIT(OVER IO,(X0CFM) CONSTRUCTION TAX
Signaturi,ofA cant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wlllthe applicant or future Wildingoccupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Reeei tic
material as defined by the Cupertino Municipal Code,Chapter 9.12.and the
Health and SafetyCode Section 25532(a)I HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes No
Wllltheepplicanto, Lure building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
A I
Quality Management Dlstrsct7 BOILER-COMP OFA'OR 1W,000 BTU)
n YeW c No P A I D
Sf ave read the hazar mus materials requirement underChapler 6.95 of BOILER-COMP(OVER 100,000 BTU) 6J ,
the GII(ornla Health 4 Safety Code,Sections 2550.5,25533 and 75534.1
understand that 11 the building does not currently have.meant that it is my NEW RESIDENTIAL MECH. SQ.FT. '��roro^, 2 9
responsibility to notify the pact of the requirements which mu at be met 9
poor to Issuance of a Certificate of Occupancy. '
CII 6 11 V
Owner or authodzad agent Date 1SSUEDB '
TO L
OFFICE COPY