23260 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification pis*M)TN2
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d l l2 S-8 CITY OF CUPERTINO-BUILDING DIVISION
c etc s ams: N : APPLICATION / PERMIT
Lie.Na. BUfLDINC ELECTRICALPLUMBING-MECHAMCAL CATECARY CONTROL N
Archlled/Engineer.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: LICENSED CONTRACTO ON oPERMITISSUANCE ❑ F1��rEl�a
^
n..L
T
Ihercaffirm that I eduMerproublnso(Chapter APPLIANCES-RESIDENTIAL
hSrcfi.r7000)offDvfi.i. heBualnrss.rdlm(elonsCdr,..dmy JOB DCKRrpON
li=-iCn ;EdLlp / PANELS
LJS2_6
Donnctor HITECPSECAO
201-1000 AMPS
ail Zp I understand my pkroshall be used as public records. OVERIOOOAMPS (V I'-�FCOQ(R�(REA S/SQ.Fr.
SiGNSELECTRICAL
<�° Llanxd P o envie al P UTE R
OWNERexNLDER DECLARATION SPECIAL CIRCUIT/
Z 9 owing r affirrmon.(Section hat 70( mph(rous a Contractors Llcenx Gw(a the
p qqqq followingrlh egir7R)IS,Businewand Professions Code:Any or
Fg euntywhlch cqubnape rot to mtutmd,alter,improve,demolish,orrepalr T6MP'ME TIfO 1.EINSf. 7
DATEI
Sad Q any structure pdorto its issuance,also requlrestheappllant for uch permitto POWER D B
U fit..igcd statement that he Is licensed pursuant to the provisions of the
Contractor's License[aw(Chapter 9(mmmenMgwith Section 7000)ofDivi.
� < slon3ofthe Buslnesaand Profenion.Code)orihathei exmpfthercfmmand SWIM GPOOL ELECTRIC VALUATION
•.1 the basis for the alleged exemption. Any violation ofSection 70375 by say O ETSSWITCHFiSiTX7l1FES
<
applicant for a permit subjects the applicantta a civil penalty of not mare than
five hundred delta.(.$500), W RESIDENTIAL ELECT,
�n ❑I,as owner of the property,or my employees with wages as their sok —SQ.FT' STORIES TYPE CONSTRUCTION
C compensation,will do the work and the structure is not intended or offered for
$' O sale(Sec.70K Business and Pro(cniuru Code:The Contractors License Law
does not apply to an owner of property who builds or improves thence,an
0.0. who does such work himself.,through hlsown employee)provided that su OCC.CROUP RFS.UNI'T'S
Improvements are not intended oroffered formic.If,however,thebuilding a TOTAL:
impmvementissold wilhinoneyearofcompldio,lheowner-bullderwlli have
tlie.tfuvden of proving that he did not build or Improve for purpose ofsakJ. QTY. PLUMBING PERMIT FEE
LJ L as owner of the property,am exclusively contracting with licensed F7.00D ZONE APN
mntndors to mretrud the projed(Sec.7044.Business and Professions Code: PERMIT ISSUANCE
.The Contractor's License Law does not apply to as..at of property who ALTER-DRAIN la VENT-WATER(EA)
Wild.or Improves therec, a
and who contacts fa such p4okcts with a
ogDf�ada(a)licensed pursuant to the Cmtmdor's License Law. BACK FLOW PROTECT.DIiNCE FEE SUMMARY
LJ 1 am exempt under Sec. B k P C for this reaennOUTSIDE FEES
DRAINS FLOOR,ROOF,AREA,CO SANITARY Y N
Owner pale RECEIPT
WORKMAN COMP Ef95AT10N DECLARATION FIXTURF-&PER TRAP SCITOOL TAX Y N
❑I hereby affirm that l have s fl-olosuate of consent to seEdnsure,a• ��,N
artinab afarkRn, gm �Guranaora emitted mpylhereof(Snc. GAS.EA.SYSTEM-1 INC. PARKFEE Y N
Polis Lab C.) �1.w m ,
Pollry p RECEIPT N
Com anv 511 � �� TSr-7.1/.(x) GAS EA.SYSTEM-01911(41(EA) BUILDING DIVISION FEES
retitle copy herebyfamished.cid. GREASC/INDU WASTE INTERCEPTOR PLANCHECK FEE
CedElad ropy k filed with the city inspect]..division.
CERTIFICATE OF O( MITION FROM WORKERS' GREASE PAID
COMPENSATION INSURANCE
(TSEWER- ARV-STORM EA 20opT Date Revel (#
Ms.ret on need net be completed tithe permit is forone hundred dollar
(5100)orfy that
WAT HEATER W/VENT/fl.ECTR ENERGYFEE 'Y N
I snot that In any personhe i any m workneer son s to bee this permit is issued, —
1 oris not employ any person In any manner at m to become eub)<ct to the tV SYSTEM/TREATING
Workems'Compensatlon laws of Gll(omk. Date PAID
-
Z Z Applicant
Z 0 NOTICE TO APPLICANT:If,after nuking this Certificate of Fieropplllon,you RESIDENTIAL PLMB.__SQ.FT. Date Recei t#
l- should became subject to LM1e Worker.'Comperuatlon provfeltuotlhe Labor TOTAL:
N Code,you most forthwith comply with such provisions orchis permit shall be BUILDING
-
deemed revoked.
U1 CL C CONSTRUCTION LENDING AGENCY SEISMIC FEE
7 hereby afnrm that there is a comtructlon lendlegageory forthe pedomr ELECTRIC FEE
Z ana ofthework for which that permit is issued(See.3097,Civ.C.) TO'T'AL:
U O Lenders.N. PLUMBING FEE
LL H Lender'sAddmae QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W lartlfythall have read Lhlsappliatbnend patethal theabove Jet if Q
ID kcormca]agra to complywlthalldtyand county ordinanaaand state laws PERMIT ISSUANCE FEES PAID:
} W
relating tobuilding construction and hereby authorize reprexntallvea ofthis
Z cltytoenter�po the above-mentioned Properly for Wpedlanpuryoecs. ALiF1iORADDTOMECH.
(We)
agmc o v,Indemnify an d keep harmices the City of Cupertino � Da
ReCeI t#
V agaWtlkbllit g daand expenan wNch may Ince ways. c AIR F9NDLINC IJMT(T010,000 CFM) SUBTOTAL•
agalrubald tyl nsn °( gr of this per-9
AIR HANDLING UNIT(OVER lo,"Cr.M) CONSTRUCTION TAX
51gwNrc afA ant/Contactor Date EXElAUSTHOOD(W/DUCH CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WOlthe applicant or future building occupantalomorhandle hazardous HEATING UNIT CM 100,000 BTU)
materials.defined by the Cupedino MunkipalCode,Chapter 9,IZ .ed the _ Date Recei t#
Ileahh and Safety Code Section 25532(x)7 HEATING UNIT(OVER 100,00)BTU) TOTA '�'
71Ya in No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Illy Management Dbtrid7 BOILER-COMP O11POR 100,0()BTU)
`
Ys ❑No
� a bavemadthehaaardoue maledals requirements under Chapter 6.95 of R01LLR-COMP(OVER 100,000 BTU) A
the Callfarnia Health h Safety Code,Sediom 25505,25533 and 25534.1
understand that if the building does not currently have a tenant,that It 0 my NEW RESIDENTIAL MECH. SQ.ET. J�
rcapotwibility to notify the occupant of the re ulremb WAR 30 1992
enwhich must be met
prior to hauance of a Certificate of Ocmpa ocy. f�
CITY�1ttCUrr I'(r
Owner or authorlud agent Date - ISSUEDBY:V�
TOTAL:
OFFICE COPY