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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Bulldin Project Identification t�
B.Hding Addms: S� L
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PERMIT NO.
20858
one:
CITY OF CUPERTIN4BUILDINGDIVISION
APPLICATION / PERMIT
A A
Cc�eract aNanc: Lk. N.
c�et
BURAINC ELECTRICALPLUMBINGMECHANICAL
CATEGORY
CONTROL
Arch11 /En neer. Lk. No: '
tilt Q�
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:jJ
❑
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm Wt l amlicensed under pmvbloneof Chapter (common,
Ingwlth Sectkn7000)of DtAsion3ofthe Busbmmand PmfeaelonsCode, and my
license is in full to. and affect.
APPI]ANCE-RESIDENfIAL
JOB DESCRII'I'ION
�.
PANELS
Llcanse Chm Lic.9
1
Data Contractor
UP TO 2DQ ANTS
—
201-1000 AMPS
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
OVER1000AMPS
/-SQ. FT. FLOOR AREA'
r� IOQ
L
S/SQ.Fr..(•
ZOI(W
SIGNSELECTRICAL
.SPECIAL CBtCN7/MISC
OWNER -BUILDER DECLARATION
I hereby afRrmthat I am exempt from the Contractors License Law for the
J
TEMP. METER OR POLE INST.
following reawn.(Section7RI1S, Bushessand Professions Code: Any city or
ountywhich requires a permit toconsttuct, alter, improve, derrolbh, ormpair
anystmd mprinrtoibktsuame,aborequtrestheapphcantforsuchpermitto
file a signed statement that he b licensed pursuant to the provisions of the
POWER DEVICES
SWIMMING BOOL ELECTRIC
OUTLETSSWITCHESFIXTURES
Contractor's License Law (Chapter 9(cemmencing with Section 7000) of Divi-
dan3 of the Ruslnessand Professions Code) mthat he b exempttheretromand
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora pemdteubjd.theapplicant to a civil penalty of not more than
VALUATION
1J .4 r`
0 ) 000
'
NEW RESIDEMTAL ECTRSQ.Ff•
five hundred dollars ($.500).
MI, as owner of the property, or my employees with wages as their sok
STORIES
TYPE CONSTRUCTION
compensation, will do the work and the structure as not Intended or offend for
sok (Sec 7064, Business and Professions Code: The Contactors License law
IN
does not apply to an owner of property who builds or Improves thereon, and
who does such work himself or through his own employees, provided that such
V.
OCC. GROUP
RFS.UNITS '
Improvements arc not intended oroffered formic. If, however, thebuilding or
Improvementbwldwllhlnaneyearofcompl&iokthe owner-bullderwlil have
tj(e)dardaan of proving that he did not build or Improve for purpose of sale.).
c Z s owner of the property, am exclusively contracting with licensed
ru on tocenstruct the project (See 7016, Buslnessand ProfeationsCade:
QTY, PLUM G RMIT FEE
FLOOD ZONE
MN
The Contractors License Law does not apply to w owner of property who
builds or improves thereon, and who contracts for such p5ojetts with a
licensed pursuant to the Contractor's LI... Law.
151 am exempt under Sec. B & P C for this reason
A Iw}}RB[[a&or(.)
FEE SUMMARY
CEOwner
IALT�t�)RAIN
,A
AA
iNC.I 5
SAMTARY Y N-
REC= X
Dates
WOR KMAN COMPENSATION DECLARATION
❑Ihereby affirm that I have a cartiicate of consent to mil -Insure, or aRFLEfPT
carti0ceteofWmke C.mpensatlon lmunnceoracertltled copy thereoffinr.
Pollry XCom
SC29OOL TAX Y_ N_
M
PARKFEE Y NPolilabCJ RECEIPT X
VER )
any
BUILDING DIV35ION FEES
�CertlRed copy b hereby furnished.
Certified copy b filed with the city Inspection division.
R
LANGHEGK FEE
GREASRTRAP
CERTIFICATE OF EXEMPTION FROM WOR KERS'
COMPENSATION INSURANCE
(This section need not be completed tithe permit b forone hundred dollars
PAIDa'
Date Rccei t#
�dt l.�
SEWER-SANRARY- RM EA
WATRIi FIFATEt W/VEM/IU.FOTR
ENERGY FEE Y N
($100)arlev3
I cartUythat in the performance ofthework forwhich this permit is issued,
WATER SYSTEM/TREATING
I .hall nor employ any person In any manner w as to become subject to the
Workers'CommUonpenLaw.of C.Ufomh. Date
AID
NEW RESIDENTIAL PLMB._SQ.Fr.
NOTIC
NOilcoE nt APPLICANT: IL after cooking this CemRicate of Exemption, you
should become.ubjed to the Workers' Compensation provisions of the Labor
Date Recei t#
TOTAL:
U
Code, you moat forthwith comply with such provisions or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
t
Ihembya(Ormthat there b a construction lending agency for the perform-
ance of the work !.,which thio permit b bsmd (Sec.3097, Civ. C.)
Lender's Name
Lender.Addraa,
I cartitythatl have read this appheatfanand state thattheaboveleformattan
bcomed. I agree to comply with all cityand countyualleancesand statelaws
relating tobullding construction, and hereby authorlu represcrualvesof this
to enter upon the above-mentioned property ectlonpurp...
(We) agree weave, Indemnify an d keep n the City of Cupertino
agaWt 11 ,N dg vent ,on,,.ndexpe kh ma In anyway a
TOTAL
EI-ECTRIG FEE
ai
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
ECHANICAL FEE
PERMIT ISSUANCE ,C
F ES AI 339
/ 67
339
ate ReCel [#
/ ALTERORADDTOMECH.
AIR HANDLING UNIT (TO 10,000 CPM)
SUBTOTAL:
against Id CI In con core gjJike - go
AIR HANDLING UNTI(OVER 10,000 CFM)
ONSTRUCTION TAX
Ignature of Appicant/Contractor Data
EXHAUST HOOD(W/DUCT)
ONSTRUCPION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UMT(TO 100,ODO BTU)
ate Recei t#
Will the applicant or future building occupant atom or handle hazardous
material a. defined by the Cupertino Municipal Code, Chapter 9.1Z and the
Ilealth and Safety C a Ion 25532(.)7
HEATING UNIT (OVER IDg00) BTU)
TOTAL:
❑ Yee No
VWITLATION FAN (SINGLE REBID)
JSP DATE
Willtheeppllcara future building occupant use equipment or devices
which emit haeardous air cents minuts as defined by the Bay Area Air
Quality Management Db ct2
BORER -COMP OHP OR 100,DM BTU)
Ves o
have read the haz au. materials regWrcments underChapter 6.95 of
' / Q T �p
�•`A5,4
A0l�199Q.
BOILER -COMP (OVER 100,0D) BTU)
the CaUf.i. Health & Safety Code, SMI v 25505, 25533 and 25534. I
orad d/hat it the bulldingdcean rrently haveatenanq that its my
oti Ility to notify the occupant the requircmentewhkh et be ,ret
,lost uance Certifkateo ry �'D,e
I�1IY asi iitwM{saw
7�1i ✓I�Btajs. Tlnq
NEW R131DI1J'DAL MECH. SQ.FT.
a carload .gen ate-
^a��Y�n
•�Y�wW,s. rs
ISSUED BY:
TOTAL:
OFFICE COPY