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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Preen Identification
Building Address:
102-01 rre kqe , •
PERIUT NO.
21953,
gee:
wnera assn: .y..
VIteC. C
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
9
3 `
Conte'Name: Lie. No:
ELECTRICAL PLUMBING -MECHANICAL
CATEGORY
CONTROL NF 7
hi /EnBUILDING
�n N C 1 1 O woeQ
ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address: 12,�� �'
N e ?-C13P,ERMITISSUANCE
129 'A E] ❑
LICENSED CONTRACTOR'S DECLARATION
I herehyaffitm that l am Ecenaed under provisions ofChapmr9(comment-
Ingwith SeMon7000)of DiNsion3ofthe Busi"mandPmfessionsCode, and my
license I. In full fora and effect.
APPLIANCES -RESIDENTIAL
JOB DFSCRR'DON
PANELS
Llan.e Clam Lk.p
Date Contnaar
UPT02DOAMPS
701-IOOOAMPS
ARCHITEC3`5 DECLARATION
I understand my plainehaObe count as public records.
OVERIODOAMPS
$[.00�$jRIjy� '
/����\\ MID
/SQ. IT
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
Ihertbyxame.(hatlam eumpnfromthe Contractor's License law forthe
followingnhmq t alin7Q1twco.nm and pr, ep e, ,.I:Mydtyor
anyked
tywhkh rcqultea permB rocoottcod, cels thea prove, dem. Wh,gr to
any assigned statement
aior to tements that
req pursuant ofpermit e
he In licensed
ills a signed statement that he L Iianaed pursuant to the provtlom of the
provisions
Contractor'. License Law (Chapter9(commencing with Section 7000) of DIA-
dorsi of the Buatessand Profmloru Code) mthat he Is eumptthenfromand
�SQ.}T.
V
M T E
PE
TE
SPECIALCIRCUIT/MISC
TIMP METER OR POLE INST.
LOWER DEVICES
SWIMMING IDOL ELECTRIC -
VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora permit subjects the applicant to a civil penalty ofnu Rn.the.
OUTLETSSWITCHESFIXTURES L
v (f
five hundred dollars ($50B.
I, as owner of the roe
property, sty, or cry employees with wages (here wk
NEW RESIDENTIAL ELECTR -SQ.Pf.
STORIES
TYPE CONSTRUCTION
work and in
structureisnot intended or offered for
r
compensation, will doBusim
axle (Sac. si ions dame law
now and Prolmbru Cade: The
to a
donson auch toanowner orproperty orContractorsimproves
apply
whodueuuch mselfor rough who nemporlmprwvided that
his ewne.
OCC. GROUP
RES. UNITS
edorough
am net If,ho eper,theb ildisuch
Improvementasnm Intended orrofcdferule.If,h
AL:
ImprovemeN tagldwithln oneyearo(completion,lhcowner-bullderwBlhave
ner-gthebuglhave
tilLIfirdenofproving/hat he did tout build orlmprove for purposeofesled.
L as owner of the property, am exclusively contracting with licensed
contracture to construct the project (Sm 7044, Business and Prolmlaru Code:
QTY, PLUMBING PERMI FEE
FLOOD ZONE
APN
PERMIT ISSUANCE
Its Contractor's License Law docs out apply to an owner of property who
Wor Improves o
proves theren, and who contracts such pPjeas with a
on
-p(fadmix) licensed pursuant to the Contractor'. License Law.
LJ I am exempt under Sec. B 4 P C for thin resaon
ALTER -DRAIN kVENT- WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS H R, ROOF, AREA, COND.
ANTT Y Y N
RECEBT N
Owner Date
WORKMAN COMPENSATION DECLARATION
QI hereby ef(Irtn that I have a certificate of ..sent to self -Inure, ora
'3800arken'Compemaalgnlmunna oraartlfled ropy therm!(See.
3800,, labb C.)
)
FIXTURES PER TRAP
SCHOOL TAX Y_ N_
RECEIPT N
S
GAEA. SYSTEM -1 INGOUTLETS
PARKFEE Y_
N_4
Policy N
RFTER'TN
GA 11A.SYSTEM- VER4(PA)
Com any
BUILDING DI VISION FEES
ertlfled copyt hereby furnished.
Csmiled copy t Ned with the city Impeeign division.
CERTIFICATE OF E'1(EMPTION FROM WORKERS'
CREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
GREASE TRAP
COMPENSATION INSURANCE
(Thiusection need mat M completed if the peemlt Is(orom hundred dollars
Date Receipt#
SEWER SANITARY STORM EA Zf10FT
WATER HEATER W/VFM/ELECTR
ENERGY FEE Y_ N_
($100) or loss.)
I certify that In the performance of the weak forwhlch this permit Is issued,
WATER SY5TFM/TREATING
L shall not employ any person In any manner so as to become subject to the
Workers' Coma
peatlon Iowa of California. Date
PAID
Applicant
NBW RFSIDFNT[AL FT.
Date Recei t#
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the WorkerCompensation pnvtioa of the Lubar
TOTAL: Z
BU D ING FEE
Code, you =at forthwith comply with such provtioa ortht permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE LNe
Ihembyaffinn that there Is a construction lending agency for the perform -ELECTRIC
arm of the work for which this permit Is Issued (see 3097, Civ. C.)
Lender's Name
Lender's Addren
I earthy thin I have read thisapplication and sate that the above information
Iscorrect.bagree ngcomply with
relating o,andhrebyacounty teerepordinances and rtatlzws
to building construction, and hereby authorize reprtsenpurposo/thin
ELECTRIC FEE
19, KID
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE,
FFEStP IU 6 snV
21
e
cdytoenteree upon to theabode-mentioned property llrepe Cit purposes.
(We) airs Is, cove, rats, co ts an d keep harmless the In
of Cupertino egaWt11abtitles, pdgment, caMsand expense which may In anyway acvue
seg net d Oty cana o the ranting ofthis permit.
8 -1-L-9
ALTER OR ADD TO MECH.
Date Reel t#
MR HANDLING UNIT QO 10,810 CFM)
SUBTOTAL'
AIR HANDLING NTT OVER lO,WOCFM)
CONSTRUCTION TAX '
Sigmwm of Applicant/Contrador Date
IXHAUSTHOOD(W/DUCT).
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
I (EATING UNIT (TO 100,ODO BTU)
Will the applicant orfuture bu0ding occupant store or handle huardous
malarial as defined by the Cupertino Municipal Code, Chapter 9.1Z and the
Date Recei I#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
Health and Safety Code Seaton 25532(2)?
MYes r1�da No
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
IQQ}
Will the applicant ser fu ham building occupant use equipment or devices
which rout hazardous air contaminants as defined by the Bay Area Air
Quality Management District?
Yea B�ZNf�.
4haveread the huardousmaterials requirementunder Chapter 6.95of
BOILER -COMP (311P OR 100,CM BTU)
BOILFR-COMP(OVER100,000BTU)
tha�-alifornia Health k Safety Code, Sections 25505,25533 and 75537. 1
underst rad that if the building don not currently have a tenant, that It is my
!.,
AUG 12
NEW RESIDENTIAL MECH. SQ.IT
responsibility to notify the occupant of the requirement which at be met
tsua sofa 1(Ic to ofOmpanry,
9fin,prlo
pp
O� Z�
a_
Owner or authorized agent Date
TOTAL:
OFFICE COPY