20616 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY '
Building Project Identification PERMITNO,
Building Address:
�y 0
S 1�� G
616
.era aces. one: -
CITY OF CUPERTINO�BUILDING DIVISION
ontaar's Name: f sec.No: APPLICATION / PERMIT
BUILDINGELECTRICALPLUMBINGMWC LAICAL CATEGORY
Architect/Engineer. Lic,No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add.
PERMITISSUANCE 12,
LICENSED CONTRACTOR'SDECLARATION
I hereby affirm that lam lkrnunderaed underprovWonsofChapter9(parmoverc, APPLTANCESRESIDENTIAL JOB DESCRIPTION
Ingwlth5ection7(Hp)o(Dlvlelon3otlhe Butlneseand Pm(eeslonaCade,and my
Ilcense is In fo`anci effM. PANELS , ^� ' �
License Cl. LI[.N 45�3�� AIF�`
Dat ConhattarLIP TO 2DOAMPS
ARCHITBCI'S DECIA ATION 701.1000AMPS
rc WWa9 O I understand my plans shall be used as public rerords. OVER 1000 AMPS SQ.Fr.FLOOR AREA $/SQ.FF.
K Y 0 Licensed Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPCCIALCIRCU[T/MISC
z .4 IherebyalO m that l am exempt from the Contractor's Lictow law for the
following reason.(Section 7131.5,Business and Professions Code:Any city or
O IEMIa.MEITIIt OR POLE INST.
� oauntywhkh rcqubeaa permit toroatact,alter,impmve,demolish,orrepalr
� aJ , qppup
POWER DEVItoe
a signed ctatement that he V Banned pursuant to the provisions of the '
1. Contractor's License Law(Chapter 9(mmmenMg with Section 70(10)of Dlvl-30VALUATION;7 alun3 ofthe Business and ProfesslonsCod0)dint he b exempt therefromand SWIMMINGECIR[ `^
0 the bash for the alleged exemption. Any violation of Section 70115 by any / OUTLETSSWI ES s] •o(V i
appBantfor a permit subjects the applicant to a civil penaltyof nal rtnretlan (O •/
five hundmd doll..(5500).
f—IL as owner at the property,'or my employees with wages as their wk NEW RESID LEL _SQFC. STORIES TYPE CONSTRUCTIONcompensation,will do the work,and thestmcture b not Intended or offered for
aa -1.C3ec.7044,Business and Professions Code:The Contractors Litems Law
does not a pply to an owner of property who builds or Improves t hereon,and OCC.GROIIIs Rk5.UNITS
who dace such work himself wthraugh his own employees,provided that such ^•OO
Improvements are notln/ended oroffered for sale.If,however,the building or TOTAL: 'V . '
Improvement l.sold within oneyearo(completion,the owner-builderwill have
t rden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBI P 1 FEE FLOOD ZONE APN
Lj I,as owner of the property,am exclusively contracting with licenaed
cop IT ISSUANCE /
contractors to construct the pried(Sec.7044,Business ami Professions,Code:
The Cmdria or.License Iaw does not apply to an owner of property who 2 AL RAIN k (EA)
builds or Improves thereon,and who cont.cia for such p(ojew with a FEE SUMMARY
mBjlactor(s)licensed punuanl to the Contractors License Law. BACK PR .D
Lj I am exempt under Sec. B It P C for this mason
DRAINS. F,ARFA,COND. SANITARY Y N
Owner DateRECEIPT
WORKMAN COMPENSATION DECLARATION F0(TURES SCHOOL TAX Y N
QI hereby affirm that 1 have a artRican of consent to opytheure,ora RpLEBxi•k
certl(Iateo(Worken'Comperuallonlvunnm oraartNed mpythereof(Sec. GAS EA.SYSTFM C40U'H.EIS PARK FEE Y N
PolicMOO;y
N CJ
Polley p DING DIVISION
N
- Com any CAS EA SY VER 4LEA) BUILDING DI VISION FIiGS
Certified copy b hod with the city CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy V filed with the city lapectlon division.
CERTIFICATE OF CI(EMPTION FROM WORKERS' GREASETRAP PAID 2
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 700Ff Date Recel 1f1
(Thlssectionneed not becompleted Bthepermiti fwanehundred dollars
($100)mleea.) ENERGY FEE Y N
I cem
rtBy that N the perfounce of the work for which this permit is blued, WATER HEATER W/VENT/ELECTR .
I shall not employ any person In any manner w mfj _ me n to the WATER SYSTEM/TRFA.RNC
Workers'Co enation law (Cpllfymh.Date 10 PAID
O Z Appllesnt a na�f c� f NEW RESIDENTIAL PLMB. QFC. DafC RCC01 NI
Z O NOTTC O PL a r ng tthis enii leo emp ion,you
should become subject to the Worken'Compewtlon proal ion of the Labor OTAL:
M N Code,you mu at forthwith comply with such provisions orthl.permit shall be BU FEE
,p
LU > deemed revoked.
(Z G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there l.a construction lendingagency for the perform- ELECTRIC
�.2 ance of the work for which this permit b bsulsi See 3097,Civ.C.) TOTAL: 9-0.00
O O . lenders Name PLUMBING Fft OO
LL F Lendee.Address QTY. MECHANICAL PERMIT FEE MECHANICAL 20.00
OW I cedifythatl have read thbappBesuonand statethat theabove information
6. bconest.I dgreeto complywith all cityand county ordinances and state laws PERMff ISSUANCE FEES—S PAIL
relating to building construction,and hereriz
byauthoerepresentativesofthb is p al G�G3
F U) city to enter upon the above,mentlored property fm inspection purposes. ALTERORADDTOMECH. Date Recei [q
— (We)agree to save,Indemnify and keep harmless the City of Cupertino P
agaWtll.blBues,jtrdgments,corsaM expenses which may In any wayamue AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL:
against said City in ronuquenceof the granting o(this permit AIR HANDLING UNIT(OVER I0,000CFM) CONSTRUCTION TAX
Signature of Appuant/Contractor Date IXHAUSTHOOD(W/DUCT CONSTRUCTION TAX PAID:
HA7A R DOUS MATERIALS DISCLOSURE
Will the applies rat or future building occupant store or Its rad le hazardous I'MATING UNIT CIO 100,000 BTU) Dat Rerni tJl
rwterial as defined by the Cupertino Mu Ncipal Code,Chapter 9.1 7,and the y��Ll _
Health and Safe ode Sectloo 75537(a)7 HEATING UNIT(OVER 100,000 BTIZ TOTAL: r
r7 Yes tNo
Wlllthe a.. imotor(uRare building occupant ussequlpment or devices. VENTILATION FAN(SINCLE RESID) - ISSU(��I�E DATE
which emit hazardou.air c'ontamiants as defined by the Bay Area Air P�u
allty Managemc bMct7 BOILER-COMP DHP OR 100,000 BTU)
Yes o
ave read the hazes out materials mqulmments under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTI!) JUL '1 1 '�yt�7u the California Health A Safety Code,Sectional and 75534.I ' L V
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.Fr. .a11.0
responsibility to notify the occupant of the requirements which swat be met peri (,CUt<1BIf1
prior to issuance of a Certificate of Occupancy. CI u
r ° ISSUEDBY:NJk�
7OTAG
OFFICE COPY