22797 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PIBLwTNO.
Building Address: I O tZ'& NI W o1-f 2 2 7 9 7
'07F_F M�m�e: one: —f! G_ A
GP*W&S '$'Powit CITY OF CUPERTINO-BUILDING DIVISION a
Ce ao()aNan : file.No: APPLICATION /PERMIT l"�'6"�1
M 550 BMLDING-EL.ECTRICALML SINGME YF NICAL CATFLORY CO.
Arc iteat/Engl r. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: I PMMITISSUANCE t S_.Qp f�-7
LICENSED CONTRACTOR'S DECLARATION LTA
I hereby affirm that l am licensed under provlvlonsof Chapter9(mmmenc MPLIANCESRESIBE JOB DESCRIPTION -
ingwuhSectlan7000)of DivbIon3 ofthe Businessand PeefessionsCode,and m
license is In full force and effect CC PANELSssar
License CVs LION_ DO s
Date Contractor - 701 ID00
e•R.FT.FLOOR ARCHITECTS DECLAR TION
DR
a4 77 I understand my plains shall be used as public remrd> OVER'MPS OR AREA 5/SQ.FT.
Licensed Profesiomul LECTRICAL Z2 �r ��1
<6 OWNER-BUILDER DECLARATION IALCERCUIT/M
I herebyaffirm that l am exemptfrom the Contractor's License Law fort
7 O�pQ5 following ason.(Scalun 7031.5, usiness and Professions Code:Any d r TEMP,METER"4I I
F7F� countywhich requirma permOtoconsbuM alter,improve,demolish,orrepalr
L Lass
anystrarnam priorto Its issuance,also requirmthe applicant forsuch permit t POWER DEVI
Bk a signed statement the he b Brensed pursuant to the provisions of the
O a 92
Contractors Llceue Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMINGPOOL ELECTRIC
rLL0 sion3 ofthe Rusinosand ProfeslonaCode)orthat he is exempt therefromand VALUATION
Sn.-11 the basis for the alleged exemption. Any violation of Section 70315 by any 3 OUTLE7SSWITC
applicant for a permit subjects the appiicanito a civil penalty ed not more than
c five hundred dollars($5M). NEWRESIDENTIALELECTR SQFf.
❑1,as owner of the property,or my employees with wages as their mole . STORIES TYPE CONSTRUCTION
compensation,will do the work and the structure is not Intended or offered for
psrle(Sec.7066,Business and Professions Cde:The Contractors License law
$ does not apply to an owner of property who builds or improves thereon,and
d-5^ who doesmuchwork hlmselforthecugh hisown employees,provided thatsuch OCG GROUP RES.UNITS
Improvements arc not Intended mattered forsale.If,however,thebullding or TOTAL: �(Q.
Improvement 1b;sold within one yea rofcompletion,the owner-Wilderwill have
the Wed en of pmving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
E-11,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sce.70K Business and Profesios Cade: If SAO
The Contracture Llcemae law does not apply to an owner of property who
builds or Improvescontractsen,and who contrafor such projects with with a ALTER-DRAIN&VEM-WATER(FA) 3, 00 FEE SUMMARY
m,�ctm(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE --
Owner
I am exempt under Sec. B A P C for this reason BACK
'
DRAINFLOOR AREA,ROOF, SANITARY Y_ N_
Owner Date RF-CERT N
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAPD6 SCHOOLTAX Y_ N_
❑I hereby affirm that I have a certifimm of consent to self-fovre,or a , RECEIPT N
certificate Cl Workers'Compensation liverance
a ora rtlfted capythemof(Sec. GAS EA.SYSTEM-1 INC OUTLETS s b PARK FEE Y N
— RECEIPT N
Pollryp
CGAS EA.SYSTEM-OVER 4(EA) INGDIVISIONFEES
C. ny
Certified copy b hereby furnished. >
Caertified copy Is filed with the city inspection division. CREASE/INDUSIRL WASTE INTFACFdsTOR LANGHEG 'E
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE IRM PAID 531
COMPENSATION INSURANCE SEINER SAMTARY STORM EA 200FT RC i t#
(Thbsection need out be completed If the permit b forces hundred dollars .,
($100)orlcss.) WATER BEATER W/VENT/E.ECTR ERGY - E Y N
I certifytfoblu
he in the perrmxnceofthe work fmwhich this permit is ed, 7•�O t
1 shall not employ any person In any manner ao s to become subject to the WATER SYST[M/TREATING 3 s �Q �pr•�i79
Ishalln temploy any Laws of any mla.mann Date
O Z Applicant NEWRESIDE ITIALPLMB. SQ FT. DatC RCcei t#
Z O NOTICE TO APPLICAM:U,a her making this Certificate of Exemption,you
FN should become subject to the Workers'Compensation provisions of the Labor TOTAL:
Code,you must forthwith comply with such proobions or this permit shall be BUILDING FEE
W ] deemed revoked.
CONSTRUCTION LENDING AGENCY �p SEISMIC FEE _
0• Ihembyaffirm that there is a construction lending agency for the perform- TOTAL, ELECTRIC FEE 4.
7 Z ante ofthe work for which this permit bissued(Sec.3097,CIv.C.) a�✓ PLUMBING FEE
LL O Lender.Name TY, MECHANICAL PERMIT FEE
LL U LenIcrb Addrcs Q MECHANICAL FEE ,Z,
O W ormc.Iagrehavereadthhappllcitbadcountathidtheyordina='zZat meion
M Lsmingt building complywall ndhereb auhommnanceeand statelzws I'ERMITISSUARCE •DO PEES PAID:
} rcy0ngmbupont construction,errieentl hemp property
ori nrcpresentativesPurpos of this
2 city to enter the above-mentioned propehinnue the Cit of C.pa. ALTEROR ADD TO MECH. DO Date Receipt#
_ (We)agree to ave,Indemnify and keep harmless the City y Cupertino AIR HANDLING UNIT(TO IO,ODO CFM)
againstesid lea,judgments,cm of
expenses which permit.
anyway acerue T. 00 SUBTOTAL:
slat said 'ty in ince of the granting of this pertnR.
AIRI NDLING UNTT(OVER I0,000CFM) CONSTRUCTION TAX
Signature of Appllant/Comrad., Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theopplicant orfuture building occupant store or handle hazardous HEATING UNIT(TO IDQ000 BTU) C7.06 Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the
Health and Srfdy Ccdc Sedio,25537(a)P HEATING UNIT(OVER 100,000 BTN TOTAL: 07,2;'
❑Yea ��]No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
whkh emit hamindous air contaminants as defined by the Bay Area Air 11pp�� pp D
Quality Maragc Dssielct7 BOILER-COMP MIT OR 100,0W BTQ P YA 1
havYeae
uo
4have read the materials requircmdnts under Chapter 6.95 of BOILER-COMP(OVER i 00,000 BTU)
the California health k Safcty Code,Sections 25505,75573 and 75536. I �p� 03 1992
understand that if the building does net co ently have a tenant,that It is my NEW RESI DENTIALMECH. SQFI`
re,ponsiblIty to Drily th omvpant oIthe requlremenlm whkh must be mren
or to bsuanmo aCerti'c sof Occupancy. I_ CIIy ur. l UpthI INV
Owner or authorized agent 'Date— TOTAL: y 2.o,V ISSUED 3Y:��- 'Ctl L1l<
OFFICE COPY