20799 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PERMIT NO.
Building Address:
1032 weqm�-rwiA 20799
Mere aw , II one:
�5— CITY OF CUPERTINO-BUILDING DIVISION
c°"tr dor'.Name: ' LIa.N°: APPLICATION / PERMIT 77
V BUILDINGELECTRICAGPLUMBING-MECHANICAL CATEGORY CONTROL
ArchBed/Engineer, la No;
q� A.N� QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addreu�II VNI 1tltE �� .
PERMIT ISSUANCE ❑ �{
LICENSED CONTRACTOR'S DECLARATION �a
Iberebydflrmthat lalv licensed under prwWonsaf Chapler9(mmmm APPLIANCFSRF9DENfGL• JOB DESCRErITON
InenseISection force and
the Buanasand ProfeseloneC-ods,and my
license Is In full(ores and dfect, a PANELS
Cl .Lk.N
Data S
ate�1�II I�%Cantuctor
- ITARCHITECPS DECLARATh OVER 100 AM
p CO ]understand my phos shag b used a public ncmds OVER 1000 AMPS SQ.FT.FLOOR AREA �r f/SQ.FT.
Fi b U Licensed Profeulonal SIGNS ELECTRICAL
<< bLE'A+ OWNER-BUILDER DECLARATION �C
tin a SPECIAL CEiCU1T/MISE
2 p,— owing aBirmthat lam31.5,Bexempt fromthe d Praleor's Licencehw for t ha
following reason.(Section 7011.$Business end r,Improve, Code:My city it
O F TEM P.METER Oft['OLE INST.
K muntywhkh requlresa permittomn,tmct,alter, demalhh,ormpalr ,
anystm=mprbrtaihismance,al3arequl stheapphuntfwr chparmltto
le a signed statement that he is licensed pursuant to the provblons of the I POWER DEVICES
asci Castaways License law(Chapter 9(commencing with Section 7000)of DIv1-
p� sbn3ofthe Buelnassand Profeselons Code)orthat hehaempn therc(romand SWIMMING POOL ELECT VALUATION
the baste for the alleged exemption. Any violation of Section 7011.5 by any 16 OUTLETSSWITCI{ESFIXI1AtES '•7 O Q
epphanlfare perrat subjects the applicant to a civil penalty of not room than l` 1 ` v o
p five hundred dollars(;500). NEW RESIDENTIAL ELECTR
L as owner of the property,or my employees with wages a their sole STORIES TYPE CONSTRUCTION
7 mmpenuoan,willdothe work andthestromme b not Intended or offered for
sale(Sec.7014,Business and Professions Cade:The Contracurs License law
ZR does not apply to an owner of property who Wilde or Improves thereon,and OCC.GROUP RES.UNITS
who does such work himself or through Ms own employees,provided that such
Improvements am not Intended oroffered for sale.11,however,the Wlldi"gor TOTAL: t co "
Improvement bsold wlthinoneyearofcompldloRtheowner-budderwlli have
tlAatrden of proving that he did not Wild or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FTAOD7DNE APN
u I,ae owner of the Property,am exclusively mntnctlng with time" pp pp I55OANCE
contractors to mnslrud the pmjed(See.7004 Business and Profession,Code:
The Carldor's Llanae Law does not apply to an owner of property who
ALTER-DRAIN&VENT-WATER(EA)
Wilds arlmproves thereon,and who mntrscts for such plp*u with a
agatIador(s)Ilcensed pursuant to the Connector's License Law. FEE SUMMARY
L j I am exemptunder Sec. B k P C far this reason BACKFLOW PROTECT.DEVICE
OUTBIDF FeE'
Owner Dm DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N
• WORKMAN COMPENSATION DECLARATION RECEITTN
01 hereby affirm that I have a rartificate ofconsent to self-Insure,or a FIXTURES PER TRAP SC i00L TAX Y N
certificate of Workers Compen,atlonleaunnce arc certified ropy therm((Sec. RE-CED'f N
moo'Lab C.) GAS-FA.SYSTEM-1 INCA OUTLETS PARK FEE Y_ N
licy
Corot S
Coronary N GAEA.SYSTEM-OVER 4(PA) RECEB'f N
Com
�Certifed copy bhereby furnished.
DIVISION FEESlehed. GRFASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Q Certifed copy Is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID r -
COMPENSATION INSURANCE SEWER-SANITARY-sroRM FA.7ooFT• Date Recei tin CJS O�
(fhb sedlon need not becompleted If the permit h(wane huntlrcd dollars t
01100)orlese) WATER HEAM W/VENT/ELECTR ENERGY FEE Y N
Imrtlfythan In the pedornunce of the work(orwhkhthb pertnitbhaed,
I shall not employ any person in any manner so as I.became abject t°the WATER SYS.fEM/,TREATING
Workata'Compensationlawsof California.Dane PAID
—
zZ Applicant NEW REMDENTIALPLMB. SQIT. Date ReceI tg SaOm
Z NOTICE TO APPLICANT.If,after meld ng this Certificate of Exemption,you
Hshould become abject to the Workem''Compomat16n provisions of the Labor TOTAL:
K N Code,you must forthwith comply with such provisions or this permit shall be BUILDING FEE 0w
W j deemed revoked.
C CONSTRUCTION LENDING AGENCY SEISMIC FEE y Z
a Ihereby afflrmthatthem isamn,trudlo"lendingagencyfor the peAorrn ELECTRIC FEE �p
Z arm afthe work for which this permit is Issued(Sec.3097,Civ.C.) TOTAL
00 Lender's N. PLUMBING FEE CX'J
LL I- Lender.Addmm QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icedlfyth.t I have read thbappliced....d statethatthe above ln(amutlan
1 bcarect.l agreeto comply with all city and muntyordinances and elate law. PERMI7759IANCE 11,C2I FEES PAID:
} relatingtobulldingmmtmdio",end herebyauthorlu reprtsen/atNesof this F 2 cityto enterupon the above-men0onad property for Inspection purposes. ALTER ORADDTOMECH.
V Z (We)agree to save,Indemnify an d keep harmless the City of Cupertino DatC Reeei t�
against Biles,jadgmenb,mpaand expe seswIdch may lnanywayaccrue AIR HANDENG UNIT(TO 10,000CFM) SUBTOTAL:
against d tty In con4*ercyofthe granting of this permv.. AIR HANDLING UNIT(OVER t0,000CEM) CONSTRUCTION TAX
1�kd/iL— I� II_
SiguhhmE of Applor EXHAUST HOOD(W/DKT) CONSTRUCTION TAX PAID:HAZABDOUS
MATERIALS DISCLOSURE
Will the .fined by or
opection,M omipalCaupant mreorhandle ter9.I and
BEATING UNIT(TE)]IX),000 BTU)
material as defined by the Cupedlm MuNtlpalCodq Chapter9.17,and the _ Date Recei IN
Health and Safety Cade Section 75537(a)7 HEATING UNIT(OVER 100,000 BTU) TOT AL• s
❑Ye. M No
Will the applicant or future building occupant use equipment or device. VENTILATION FAN(SINGLE MID) FIANCE DATE
which emit haaerdous air contaminants as defined bythe Day Arca Air �rJq R/rh
Quality Management Din❑sMd7 BOILER-COMP(JEEP OR 100,OM BTU) t`iND
No
4haveraad the hazardous materials requirements un der Chapter 6.95 of BOILER-COMP(OVER 100,000 B1U) OCT 1 •(
the Cahfemg Health&Safety Code,Sections 25505,75533 and 75534.1 C 1
understand that l(1hebWldingdcea nm mmently havealenanq that ltbmy NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requirements which most be met
Prior to Issuance of a Certificate of Dow pa ncy. fit of Cupfin
Owner or authorised agent Data
TOTAL: L CFCJO 15SUEDBY:
OFFICE COPY