20152 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
But din a Ida fiatlon - PE TNO,
Building Address: I r - 194 20152
n e aces: LI O4) VIS l+
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y� 1C,0 aZ CITY OF CUPERTIN68UILDING DIVISION
Contra 'aNan'e; Lic.N : APPLICATION /PERMIT v
BUILDINGELFCTRPCAL-PLUMBING-MLCHANICAL CATEGORY CONTROL
A=It�/Eagiaaxan. Lt.N.
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE (� ❑ 1:1 [:JLICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(mmmenc- APPLIANCE&RFSIDENTIAL ]OB DESCRIPTION
Ingwlth Seaton7OM)of DiV m3afthe Buslnesand PmfeWunsCode,and m ,
Licnso Cims fora and M(ca. PANELS C� �p
LI38ns Clara Lich L 66�r _�,ar�`•_.�,''
Date C°mraRor
ARCHITECTS DECLARATION 201-1000 AMPS
pQ+Q CO I understand my plans shall be used a public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
F00 Licensed Professional SICISSELECTRICAL = 1 KI A ID '�
OWNER-BUILDER DECLARATION Is$PECULCIRCNT/MLSC CE
1.. a Iherebya(Drm lMtlace exempt fromthe Contnctorb Licemelaw(a the
following reason.Section 7MIZ,Business and Pro(esslom Code:An city r
p4 ja Y ty° TEMP.METER OR POLEINST.
�� muntywhlchrequiresaper ttommtmetalter,lmpmve,dem°Wh,orrepalr
S a anystmmm pdartoits Issuance,also requlrestheappliam for permit to POWER DEVICES J/� n�
U file a signed statement that M is licenced pursuant to the provisions of the �/' `7
�O0 G, G°ntnetore License Law(Chapter I(commencing with Sectlon 70001 of Divi- SWIMMING IDOL ELECTRIC ALUA N
Og alon3 o(the Business and Penfeeeima Gode)mthat he b exempttherefromand
y the basis for the alleged exemption. Any violation of Seaton 7(13"by any OUTLETSSWITCHESFTXfURES
.yam applicant fora permit subjects the applicaetto a civil pensity a not mom than
q five hundred deltas(4500). NEW RESIDENTIAL ELECTR SQ.FT, STORIES TYPE CONSTRUCTION
❑1,as owner of the property,or my employees with wages as their sole
FQ, compensation,will do the work and the structure is not Intended or offered for
sale(Sec.7014 Business and Profeshme Code:The Conlraaoe.License law D
$� doesnolapply to an owner ofpmperty who builds or improves thereon,and OCC,GROUT' RFS.UNITS
who deassuch work himself orthrough his own employees,provided that such ��
Improvements am not Intended proffered for sale.If,howevep thebuildleg or TOTAL; CC
Improvement i,.td within oneyearofcomplMWNtheowner-buDderwlll have
tkelzurden°(pmving that he did not build or improve forpurpose ofsale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
L j 4 as owner of the property,am exclusively contracting with licensed MPERMIT ISSUANCE
naan to Wa the projM(Sce.70K Business and Professions Code:Cant of s lanae law does net apply to an owner of property who ALTER-DRAIN&VENT-WATER(PA)
builds o P ves t aeon, d who contracts for such pNkcts with a
ca .emed� suantt he Contractors Limme,Law. FEE SUMMARY
a m m e u'urer ec. B&P C for thisOUTSIDE
1. maven BACK FLOW PROTECT.DEVICE
- DRAINS FLOOR ROOF,ARE&OOND. SANITARY Y N
Owner Date RFOIRT N
WORKMAN COMP, SAicam of can.
ION FIXTURES PER TRAP SCHOOL TAX Y N
❑I herebbyy affirm that 1 have• Imum.e of.onset to opytnmre,(Sa RECEIPT N
3800,lAbCfWorkersCompensatlonlnsuranaoraartl(kd mpythereof(Sec. GAS FA.SYSTEMfl INCA OUTLETS PARK FEE Y N
Polis lab C.).
Polity N RECEGAS EA.SYSTEM-OVER 4(EA) DING DI M
Com any - BUILDING DI VISION FEES
Go
CertRled copy is herebye
C]Certified spy V liked with the city inspection division. GRFASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY STORM EA 20OFT DRIB RCceI [#
(Thl.salon need nM be complMed i(the permit V(°rpm hundred dollen
($100)aWATER Hr•ATERW/VENT/ELECTR ENERGY FEE Y N
Icertify(y that In the performance
o(the work forwhich this permit is Issued,
I shall not employ any person 0n any manner soes to become subka to the WATER SYSIPA{/TREATING
Workers Compensation Laws of California. Date PAID
C• Z Applicant Date Recei t#
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you NEW RESIDENTIAL"B. SOFT'.
Fshould become subject to the Workers'Compensation provisions of the Labor TOTAL:
N Cx1e,you mumforthwith comply with such provisions onhh permit shall be
> deemed revoked. BIN G FEE
jL O CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby afBrmthat there b a mnstmction lending agency for the perform- ELECTRIC FEE
M Z arrr.ftheworkfu whichthb permit le Lsaued(Sec.3097,CIv.C.) TOTAL:
V O lender's Name PLUMBING FEE L-f All
LL h- Lender's Addres QTY. MECHANICAL PERMIT FEE MECHANICALFEE
I38di/ylhatl have read thbappllation and matethatthe abovelnformatian
O W rr
Iscoea.I agree to comply with all cityand me
untyordlnanoand nate laws PERMIT ISSUANCE FEES PAID:
r a relating to building construction,and hereby auth°rlee representatives of this
f-. N city to enter upon the aboveneenlioned property for inspection purposes. ALTER OR ADDTO MFGH.
? (We)agree to save,Indemnify an d keep harmless the City of Cupertino •Date RCCCI t#
V agaWt BablDtlee,judgmanb,note and expenses which may In any way accrue AIR HANDLING UNIT(DO 10,000 CFM) SUBTOTAL:
against said City In come uenc,of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CEM) CONSTRUCTION TAX
Slgnsture of Applicant/Contractor Date EXTLkUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuturc building occupant store or hand to haaardom HEATING UNIT(TO 100,000 BIIn
material as defined by the Cu pertlno Munidpa l Code,Chapter 9.1 2,and the RCCCi f#
I lealth and Safety Code Secilon 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes MN.
Will the a ppllcant or human building occupant use equipment or devices VENTILATION FAN(SINGLE RFSPD) ISSUANCE DATE
which emit haaardous air contaminants as defined by the Day Arca Air
Quality Mansgempnt D❑isMa7 BOILER-COMPpHPOA 103,IXD BTU)
QYes N No Jw MRlll�l:
If. sad thehaza 1. matec,Lsrequircmenh5533.rhapler 6.95 of BOER-COMP(DV1B 100,000 BTU)
the II(o Ice i4ealth&Sa(My Code,SMlom 25505,25533 and 255M. I }1{�❑ ��� .
u dte� dat if the builds oea not currently have a tenant,that It b my NEW RESIDENTIAL MECH. SQ.Fr.pion t ocmp nto(thertyulremennwhich tis metdoce of C Bal ° Oavpanry.
u �d
ONQZr 3'y W wWs
r aulho0red agent le
TOTAL: ISSUED BY:
OFFICE COPY