20815 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project IdentificationPERMITNO.
Build-CA 3 /m _ � _ 20815
aoe: one: MTCNM=DAM
caner.Nl?S / CITY OF CUPERTINO-BUILDING DIVISION
Contractor's Name; W Lie,Nn: APPLICATION / PERMIT
I N J X393n BUrLDING-ELECnUCAI PLUMBING-MECHANICAL CATEGORY CONTROL#
Architect/Engineer. Lie.Na:
QTY BUILDING PERMIT INFO
ELECTRIC PERMIT FEE
Addraw PERMITISSUANCE ❑ EJ Ej
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL I hereby affirm that I arnbcamed under provisions of Chapter9(commenc JOB DESCRE'TION
ingwhh Sedfon 7000)of DlNk.3ofthe Busin sand Professions Code,and my
Ilanse is in fuB force and effect. PANELS `
Lianr Clar Lk.N
Date Contactor UP TO 2DO AMPS
2011000 AMPS
ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA /SQ.FT.
q�q�uu re0 20 I understand my plans shag be used r public records.
E' Llmnsed Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECIALCIRCU1T/MISC
F, Iharebyaf0rmm
that l aexempt from the Contmdor's Lim se Lawfmthe
following...(Section7031.5,Budraaa.nd Profeaskma Code:Any city or TEMP.METER OR POLE INST. ,
F� wuntywhich requbesa permit mwntruct,alter,improve,derrollsh,ormpalr
6�sGG anystructure prior to its L+wawgalw mqubn lheappb¢nt for such permit to POWER DEVICES
m Ole a signed statement that he is licensed pursuant to the provied..of the
O Contractor's License Law(Chapter 9(commencing with Section 7000)of Div I. SWIMMING TOOL ELECTRIC VALUATION-
t.30 Mon3 of the Business and ProfaxeinmCode)orthat he is exempt themfrom and ' Q
Gthe basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLEISSWITCHESFIXTURES i4 O� s LI V
O appUc.ct fora permit subjectstheappllcant toa civil penalty of not more than ll Q
five hundred dollars(5500).
❑1,as owner of the prop ,or my employees wages as their sole NEW RESIDENDAL ELECTR SQFT. RIES TYPE CONSTRUCTION
compensation,will do the work,and the struchare is not Intended or offered for
O .1.(Sec.7094 thamexs and Proferion Code:The Contractors Li¢rse Law
$$ don not apply to an owner of property who Wilds or improves thereon,and OCC.CRO(IP RES UNITS
who donsuch work himself crthrough hisownemployees,provided thatauch
improvements arc not Intended proffered forsale.If,however,thebullding or TOTAL:
Improvement Bwidwlthin oneyearofcmnpl&tW theowner-buitderwillhave
t"rdan of proving that he did cart Wild or improve for purpose ofasle.). QTY. PLUMBING PERMIT FEE FLOOD TONE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
..trade.to comtruct the project(Sec 70K Rusin.and profession,Code:
The Contactors License law don not apply to an owner of property who ALTER-DRAIN&VENA-WATER(EA)
build.or Improves thereon,and who contracts for such pAojem with a FEE SUMMARY
oqt tt actor(a)licensed pursuant tothe Contractor's Lkense Law. BACK FLOW PROTECT.DEVICE
!J I am exempt under Sec B&P C for this rescan OUTSIDE FEES
DRAINS FLA,FLOOR,ROOF,ARECOND. SANITARY Y N
Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATIONZ�.I.RAP SCI100L TAX Y_ N_
QI hereby affirm that I have a¢rugate of consent to se8-invert,m• RECEIPT Y
certificate of Wmkers'Comperaatkmlruranceara artlfied cepythereof(Sec. GAS EA.SYSTEM-I INCL OUTLETS PARKFEE Y_ N_
3800,lab C
Pdic Y q RECEIPT N
Com
rIany U GAS EA.SYS7EM-OVER4(EA) - BUILDING DIVISION FEES
Certlffed rop"hereby furfilshed. GREASE/INDUSTRL WEPTOR PLANCHECK FEE
!�dmed copy Is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKER IGREASETRAP PAID
COMPENSATION INSURANCE -SANITARY-SID Date Recef t#
(Thi.aecuonneednot becompleted 8lhe permit lefor but a '
(51D0)mless.) A } TER / / CTR ENERGYFEE Y N
I¢rtifythatlntheperforman¢oftheworkforwhicM1 th pe its
I'ahall not employ any person In any mann w r to ject1 1 A TlN'G —
WorkeriCompenudonLawsofCalBomia. ate PAID
—
0 Z Applicant RE9 AL PLMB. SQ.17. Date Recei t#
Z O NOTICETO APPLICANT:If,after making V B of m on,you
should become subject to the Works.' t prov to o eLaomA TOTAL: „
f/) Code,you at forthwith comply with site to t is _rmit steal _ BUILDING s`
deemed revoked.
W c CONSTRUCTION L ANG ACEN SEISMIC ITE
I hereby affirmthat there is a wcut I mending agen f HE or ELECTRIC FEE
D Z arcs of the work far which this permit wed(Sec.3097,CIv.C.) TOTAL:
V O Lerutae.No PLUMBING FEE
IL I— Lender.Addmr QTY.I MECHANICAL PERMIT FEE MECHANICAL FEE
U Icedlfythatl have mad thisapplicauonand date thattheabovelnformauon
O W iscorred.I agreeto complywlth all cityxnd county ordinances and nate laws PERMITISSUANCE FEES PAID:
} 1 relating to building wmWcticn,and hereby authorlae representatives of this
Zcity to enter upon the above-menuonad property for Inspection purposes. ' ALTERORADDTOMECH. Date ReCel t#
(We)agree to save,indemnify and keep harmless the City of Cupertino
V againd llabWcln,}udgnants,costs and expenses which may In anywayacmue AIR HANDLING ILMI(17010,000 CFM) SUBTOTAL:
regal uld
City n en¢oI the renting dthis permit.
. M � i 7_ 9� AIRHANDLINGUMC(OVER10,000CFM) CONSTRUCIIONTAX
gnature of p nt nadmb
Data EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wllltheappllant.,fumrebullding.panbtoreorhandleh.z ,dous HEATING UNIT(TO 100,000 BTU) Date Recef t#
material as def cud by the Cupertino Municipal Code,Chapter 9.17,and the
fiealth and Safety Code Section 25532(A)7 _ HEATING UNIT(OVER 100,000 BTU) TOTAL:
L�
F1 Yea No
1$$UANC(E DATE
Will the applicant crfuture building occupant use equipment or devices VENITLATION FAN(SINGLE RESID)
which emit haaardous air conga mhants as defined by the Bay Area Air
Quality Management District) BOILER-COMP OI-Es OR 100,000 BTU)
4Yea No +A
no have read the haaardous material,requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California f iealth&Safety Code,Sections 75505,75533 and 75534. I .It)l— it G
understand that if the building does not currently have a tenant.that It is my NEW RESIDENTIAL MECH. SQ.FT 431 LL
responsibility to notify the occupant of the requirements which most be met p y
prior to issuance of a Certificate of Occupancy. ptlu yVpe„In� Ls Q�1
Ownerorauthommdagent Data TOTAL: ISSUED BY..'\ ov"J
OFFICE COPY
I