22986 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
ofiulld Ng a73 7 ,eo® w64L 22986
IQ73 one CITY OF CUPERTINO-BUILDINGDIVISION'glob {� (�
con agora me: LIallo: APPLICATION /PERMIT I
a. � 6
ryS 7 VO BU LDINGELECTR CAGPLUM CATEGORY CONTROLN
It'/Englmer. Lia N. BINGMECI{AMCAL
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add-11?5" �. Suti� p- C IrZ7 PERMIT ISSUANCE El11LICENSED CONTRACTOR'S DECLARATION
Thereby affirm that l am licensed under provisions of Chapter 9(mmmene APP11ANCESRFADENTIAL
Ing with
JOB DESC ON
licameI.h Section
ion NU 7000).f effect PANELS
B�atnessandl'coleWonsCode,and my
I. 7000)and
dfett. PANELS `V`T`l
License Clam Lic.N_ )Il YO _`
Dd"AL L Cmuuactor J0111%
ARCHITECTS DECLARATION 201-1000 AMPS
9O Zp Iunderstand my plans shall be used upubllc records - OVERIMOAMPS FL $/SQ.Fr.
E 5(� Llcensed Prolessioml SIGNS ELECTRICAL p A TTT C
71<'q y
OWNER-BUILDER DECLARATION SPECIALCRICUIT/M15C ,V, U {/r i
Ihereb a(nrmtOWNE -BUI from the DECLARATION
License Law for the /
oo following mason.(Section 7031 S,Business and Professions Code:And r
KZI' cauntywhichrequlresaper tiomr cyalwr,impmwdennlleh,or pair TpMP'METLI(ORI'OLE INSI. TFnA
anystru=ture prior toitsbgame,also requiresthe applicant for such permit topOWgR DEVICES
file a signed statement that he la licensed pursuant to the provisions of the
3u' :ContraOmrb License Law(Chapter9(on..cleg with Section 7000).!Divi- SWIMMING POOL ELECTRIC
SOS dion3 ofthe Business and Pro/eulomCode)orthat he is exemptthereVALUATIONfromand CO the bash for the alleged exemption. Any violation of Section 71131.5 by any OUTLETSSWITCHESFIXHIRFS
<S appRcantf.raper tsubjeRstheappBcanttoadWlpemlty.f .a.rtthan
.five 1,as
d0llanhepr. - NEW RESIDENTIAL ELFCTR_SQ.FT. STORIES TYPE CONSTRUCTION
(� ❑e as owner of the property,or my employees with wages as ff, mit
C < mmpec.70 ,Business and
intend�Contactor.or.Yore'(.], t'
9 ❑ 'vk(Sea 7f144,in a Business f property who
b:The uilds or Imp Rora hereon iaw
des not roan owner ofthroug ywhonorlmproves ovidedreoryand OCC.GROUP RES UMTS
FF
who doementswork him¢Borthmughh6own .If,however,
oemployees,praise dthat g or
Improvementsareout intended.],offered(.reit.Il, owner-y hider ill haw TOTAL:
Improvement lentis withlnomyearofcomp!'iorythe owner-bunderwlll have
tla.IIurden of proving that he did not bund or improve for purpose o(nk.). QTY, PLUMBING PERMIT FEEFI.00D7ANE APN
u 4 as owner of the property,am exclusively extra'.."with Ii _ PQ2MI.I.I56[1ANCE
contractors to mmtrud the joined(Sec.7044,Business and Professions Code:
The Contractor)License Lw does not apply to an owner of property who ALTER-DRAIN k VENT WA7F$(EA)
builds or Improve thereon,and who contra' m.lar such ptojewith aFEE SUMMARY
cgp((a'orbvtl m)Ikenpursuant the Contract e.Llmnx Law. BACK FLOW PROTECT.DEVICE
LII am exempt order Sac B k P C for that moon
OUTSIDEF
Owner DRAINS.FLOOR ROOF,AREA,CONTI. SANITARY Y N
Date RECENT N
WOR KMAN COMPENSATION DECLARATION FDnURES PER TRAP ��� SCHOOL TAX Y N
-QI hertby affirm that I have a cartl(lote of consent to ae161ngre,ora RECEIPT N
certificate olWorkers'Compemation Insurance ora certified copy there.((Se.
3800,Lab CJ GAS EA.SYSTEN-1INCA OUTLETS PARK FFE - Y N
Policy N RECEIPT N
Com an GAS EA.SYSTEM-OVER4(EA)
Y BUILDING DIV]SION FEES
Grtined mpyla hereby"rnlahee. CREASE/INDUSTRL WASTE B4TFdtCF1'IDR PLANCHECK FEE
Ce Certified copy k filed with the tlty Inspection division.
CERTIFICATE OF F7(EMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEINER-SANITARY-sroRM EA.200FT Date Receipt#
IThla section need not be complded If the permit la Crone hundred dollar
(f1IX)a1css3 WATER HEATER W/VENT/fl-prTR ENERGYFEE Y N
(certify that tithe pedrson In any
h. itmanner an i tobehbpenNtla blued, —
I shall not employ any person f any manner at u to become gblett to the WATER SYSTEM/TRFATING
Worken'C.mpenutlon Lawtof GB(omla.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ,FT. Date, Recei i#
Z O NOTICETOAPPLICANT:If,after making this Certificate of Exemption,you -
CC CC should become subject to the Workers'Compensation pnevkbra of the Labor TOTAL:
t/3 Code,you at forthwith comply with such provlaaons or this permit shall be U •E ^�
> dean d revoked.
IL G CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z
I herebyalnrmthatthere b a conotrudlonkndingagenryftrtheped,0m T . _�� ELECTRIC FEE
anaofthewm1cforwhichthla permit is Issued(Sec.3097,CIV.C.)
U O Lenders Name PLUMBING FEE
IL F Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICALFEE
O W Imect. tagre to
with alcityndcuntyordinanceseld date laws
1 kmingt Iagreeto comply with andtyand county ordinances representatives
end date
softws PERMTTISSIIANCE PEES PAID:
} N rely to enter
ru pont construction,enion hherproperty odu reprexnpurpos0(thk
H Z citytoagree
to caw,he levcmenila.d her.,],Inspection purpose. ALTER OR ADD TO MECH.
—55 1(We)agree to saw,IndemNly an d keep hormions the City o/Cupertim Date Recei t#
against liabilities,iadgments,cote and expenses which may m any way accrue AIR HANDLING UNIT(170 to,=CFM) SUBTOTAL'
against said Ci an comryuame of the granting of this permit
�C AIR HANDLING UNIT(DYF]t 10,000 CFM) CONSTRUCTION TAX
�jgha2p Or Appimnt/contractor to- EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle harardoua HEATING UNIT(-70100,000BTM Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9,12,and the
I lealth and Safety Cade Section 25532(a)? HEATING UNIT(OVER 100,000 BTU TOTAL
Is
oYu No pp�y�,�
Willihe applicant or Nre building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) AltSUANCE DATE
which emit haeardaua air entaMmnts as defined by the Bay Area Air
lily Management District? BOILER-COMP PHP OR 100,0(D BTU)
u�u v. n No p� V 5 199
iluve read the ha>ar�,us nuterials rcqulrcmenro under Chapter G95 of BD)LER-COMP(OVFR 100,000 BTU) Ili® 1 1
the Gltandt that
kSldin Code,sectlountly have
ate nd75534,undeI
responsibility
that notify
the occupant note requirements hick that it bey NEW RESIDENTIAL MECI{. `•'Q hT /0 OF CUP '
nspomib0lty to naltythc occupant.f the requirements which must be met C7Y EI'ITINU
prior to Lssuance o!a Certificate olOmtpanry.
Owneror authod>nd agent Data ISSUED B` C7`]�•��yl
TOTAL: mal✓{I�Q.l
OFFICE COPY