21004 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification 7
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Building Address: n O 0 A
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��� S �(� CITY OF CUPERTTNO-BUILDING DIVISION ��� I �yO
Contan�Ror's Nanr: Lic.Na APPLICATION /PERMIT L--
c+V BUILDING-ELECTRICAI.PLUMBI NGMECI IAMCAL CATEGORY CONTR(X,:a
Architect/Engineer. Lic.Na C�(,[,J`�
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: ( PERNOTISSUANCE IK
LICENSED CONTRACTOR'S DECLARATION LP
T hereby affirm that l am licensed under pmVIAomof Chspter9(mmmmn APPQANCESRESIDENIIAL JOB DESC 10N
Ingwith Secilon7000)of Divlalon3 ofthc BusineseanciPenfesslonsCode,and my
license is in fiulV0,me and o feet' e-'�_LIE?
� '7 e?` PANELS
Llcen�Cr lretractor J"C�I F-J ,
Date JJ GECI2011000 AMPS ���lll
ARCHITECPS DECLARATION
mO ZZC I understand my phns aha0 be used v public remNa OVER 1000 AMPS �.FT.ILOOR,A,{R.,EA elf/SQ.FT.
Fe Z U Licensed Professional SICNS ELECTRICAL W �l w,1 e.L 1 1 1 y 0.
<<<ou
y OWNER-BUILDER DECLARATION L-V L •-•a /-1l!
rn SPECIAL CIRCUIT/td15C
Ihercbyaffirm ttitlatm exempt from the cnntractorb Licenx law for the
Z P- n following reason.(Seciion 7W IS,Business and Professions Code:Any dty or
O6HQcoun hlchrc Ircsa rmlt to construct,alter,int demolish,orrc air IEMP.MEI'�20R POLE INST.
county requires pe prove, p
F< M� anystrocturepriw to Its iswance,absg rcqulmtheappllant forsuchpemdl to PDWERDEVICFS
N C E,U Ole a signed statement that M Is Hom add pursuant to the provbdons of the
�3 t`In Contncior'e License law(Chapter 9(rommenMg with Section 7000)of DTvl- SWIMMING PO OL ELECTRIC VALUATION
L,j O aIm3 ofthe Business and ProfessionsCode)orthat he is exempt therefromand t
O the basis for the alleged exemption. Any violation of Section 7ML5 by any OUTLETSSWITCF11S-FI TURES O /
applicant fora permit subjectsthe applicant toa civil penalty of net more than 1
fivehundrceldollara($5(10). NEW RESIDENTIAL ELECTR SQ.FT.
❑I,as owner of the property,or my employees with wages as their sok STORIES TYPE CONSTRUCTION
SPG compensa I..,will do the work and theatruature b nM intended or offered for
5 p site(5cc.7046,Bus xxx and Penfexim,Code:TM Contractors Licerue law
�$g does nm apply to an owner of property who builds or improves theme,and OCC.GROUT' RFS.UNITS
who does suchwork himself or through his own employees,provided that such
Improvements are no(lntended oroffered forsale.If,however,thebullding or TOTA :
Improvement u sold within ooe ycarofcompleHoo,the owner-bullderwill have
ft9urden of proving that he did rest build orlmprove for purpose ofsale.). QTy, UMB[ IT FEE FLOOD ZONE APN
[_f I,as owner of the property,am exclusively contracting with Ilce— PFRMIT UNAtE
contractors to construct the project(Sec.7046,Business and Professions Code:
The Contractor's License Law does net apply to an owner of property who �.�-pAAI -WA- (IA)
builds or improves thereory and who contracts for such pkojects with a FEE SUMMARY
cQO.tjanor(s)Hmneed puxuann to the Contractor's Licenx Law. BACK FLOW O 'T.D
LJI am exempt under See. Been P C for this reason
SANITARY Y N_
• Owner Date DRAINSOUTSIDE]:ITS
F, D. RECEIPT
WORKMAN COMPENSATION DECLARATION TRAP SCI-1001,TAX Y_ N—
❑1 Femby affirm that I have a certificate of convent to selMnsure,ora RECEIPT N
mai0oteofWork Compensation[roumnceoraceHified copythereof(Sec. NC ETS PARK FEE Y N
3800,Lab C.)
AECEPT N
policy STEM VER (EA) BUILDING DIVISION FEES
�m any
Certified copy is hereby tumity, CR! E/INDUSIRL WASTE I R PLANCHECK FEB
�Certltled copy V filed with thee dty inspection division. ( —7
CERTIFICATE
CERTIFICATE OF EXUAPTION FROM WORKERS' Gmoo PAID (
4L
R .
�l (LJ � `aG10
COMPENSATION INSURANCE Revel t#
(Thlsaection need not bu completed tithe permit V(Drone hundred dgllart .SANTFARY-STORM FA Date
s
(f100)oHex.) NATER HEATER W/VENT/ELECTR ENERCYFEE Y— N
I certifythat in thepadm.nceofthework fwwhichthioprddt faissued, �� /��
1 shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TRFATING PAID�jALXW )!V
Workers'Compensation Laws of Califomla.Date
Oct
Z Applicant NEWRESIDEMIIALPLMB. .FT. Date Recei t# w
Z O NOTICETO APPLICANT:If,ofter making thisCertiOateof Exemptlon,you
should become subject to the Worken'Compevatlon provislonsof the Labor TOTAL:
CC N Code,you must forthwith romplywlthmch provbsLmsmthis permitshallbe BUIL IN11
deemed revoked.
W CONSTRUCTION LENDING AGENCY Q SEISMIC FEE
CL Iherebyaffirmthatthem isaconstruction Lending agency for the perfom TorpL: ELGCTRICFEE (3J
:) te Z anof the work for which this permit Is Issued(Sec.3097,Civ.CJ
02 Lender's Name PLUMBING FEE
H Lenders Address QTY. MECHANICAL PERMIT FEE
LL MECHANICAL FEE
O W Imrd.Id that
eretoc comply
sappbatynand dcomtethatt maces telnfomuaou
S i mating to
building comply wo,andhereb authorize nanm and xtativesofthis PERMIT ISSUANCE FEES PAID:
>. city to glob upongronswction,and hereby of this
FN citytoto ave,Indemnify an d property harmless
Cit p of Cu
ALTER OR ADD TOMFLH. (��
? (we)agree m nave,Indemnify an d keep harMex the City of Cupertino Date Receipt#
V agalnstllabllltles,ii dg s,2stsa d expenses which may in anywayadarue AIR HANDLING UNIT D'O IQODO CFM) SUBTOTAL:
against gal.: Inc he grant crtnit
AIR HANDLING UNIT(OVER 10,000 CIM) CONSTRUCTIONTAX
naturcp cant/Contra Dat EXHAUSTFi00D(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant storeor handle havrdous HEATING UNIT(TO 100,000 BTU) Date Remi t#
material as defined by the Cupertino Municipal Code,Chapter 9.IZ and the —-
HeallhandSafety Code Section 25532(a)? FIEATING UNBT(OVER IW,000 BTU) TOTAL:(-f6'611
❑ Yea [j No
Will theappllcentorfuture building occupant usedfulprrcnt or devices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which emit harardom air contaminants as defined by the Bay Area Air
• Quality Management District? BOILER-COMPOHPOR 100,000 BTU) n
Yes P
No
have read the Fara cam materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BN)
the California Health&Sa( Code,Sections 25505,25533 and 25514. I s V Q
understand that if the building does not currently have a tenant,that It is my NEW RESIDENfIALMECFL SQ.FT. tlyI J � +
90
morto Issi nce of aCeheic to of Occupancy.requlrcrrentswhich must be met
prior to Issuance oto Certificate o(Occupanry. pTgat �I-"'tLL
Owner or authorized agent Date TOTAL: ,,..a9tes ISSUED BY.
sW
OFFICE COPY