23576 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proen Identification PERMITNO.
Building Adtl(4 - ' q�, - 23576,
one: A
CITY OF CUPERTINO-BUILDING DIVISION
1CK&qv.N.._: LIeN°, APPLICATION /PERMITBUILDINGELECTRICA MP BINC-MF IIAMCALCATFSARV CONTROL M
.hk. a
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addresseot d PERMIT ISSUANCE ❑ ❑ EJ
DEC LA ATIO
I hereby affirm that l am licensed under provision'or Chapter9(m en APPUANCE-RESIDENTIAL JOB DESCRU'IEON
ingwith Section 7000M DlW .3afthe Budneeand ProlessimsCode,and my
license Is In full force and affect. PANELS
icense Coro Lle.a
Date Contractor UP TO 200AMPS -
ARCHITECPSDECLARATION 201-1000AMPS
0'O Iunderstaad my plansshaU 1. and as public resents, OVER1000AMPS SQ.FT.FLOOR AREA f/SQ.FT.
FL Licensed Professional - SIGNS ELECTRICAL
<6
OWNER-BUILDER DECLARATION A L E D I IV
In a SI'FfIALCU2CUlT/MIST
Y� Ihercbya(llrtnthat lam exemptfromthe Cont ractolaLlcenee Law for the '
(allowing reason.(Section 70315,Business and Proferolons Code:My city or
Ko TEMP.METPRORIOI.EINST.
county requlmapermitromtuttuct,alter,Improve,demalish,or repair
anystm=mpriortoitsisssane,al mquirestheappllcantforsuchpermitto POWER DEVICES
4 file a signed statement that he is licensed pursuant to the Emwisloru of the
W Contractoes License Law(Chapter9(mmeaneingwith Section 7000)ofDivi.
30J Non3ofthe Businesand Profeularu Code)orthat heisexemptiherefromand SWIMMING POOL ELECDAT
TRIC / ON
Q.•�77 the basis for the alleged exemption. Any Wolatlon of Section 70315 by any OU7LETSSWI7CHESFlXRIRFS
applicant fora permit subjects the applicant to a civil penalty of not more than
five hundred dollars($500). S
TORIES TYPE CONSTRUCTION
NEW RESIDENTIAL ELECTR FT.
GGG111 �n ❑I,ac owner s(the property,orheemployees with
ended a theles ale
compensation,70K will doBlume s ahe work,and ions Codc;reisrsot intended or offered for
p sale(Set.apply
to Businessand
property
Gds.The Contractors Lim.there, Law
�$ does not apply torn owner or throng his obuilds nemparlmp prowde that such
CC.GROUP RES UNITS
EEE whodaemntsaormil tell or dedoroughhbawale.ILywewrthebuidlegoh
Impmvementsarenotintenomyearofco (orsalkthe oweveLilder illhave TOTAL: '
Im.turdeentpsoldwithin hedid otcoildorirythe , ner,bufaprposeafulove
t men ofner of the
property,a emus bnprove resting with licensed
QTY. PLUMBING PERMIT FEE
on I,er owner of the property,am exclusively ces and Pro with Professions
ZONE APN
Th Co an to cmuW License
La does(Sre.
not 70Kapp!Booms owner
Pf reopen Code: PERMIT ISSUANCE
The Contractor's License law don not apply to;f owner of property who ALTER-DRAW k VENT-WATER(EA)
builds or Improve thereoa,and who mmrans for such paojem with r FEE SUMMARY
cl5aldor exempt
pursuant to the Contraccola License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec- B k P C (or this reawn
DRAINS.FLOOR ROOF,AREA,GOND. SANITARY Y N
Owner Date RECFIlrT p
WORKMAN COMPENSATION DECLARATION FDCFURES PER TRAP SCHOOL TAX . Y N
❑I hereby affirm that I have a certificate of consent to calf-Insure,or a RF-CFRs'I'p
certificate of Workers Compensationlessen or a certUled copy thaomf(5ec. GAS F.A.SYSFFM-1 INCAOUTLETS PARK FEE Y N
3800,Lab C.) RFCEB'T p
Policy p GAS G.SYSTEM-0VER 6(EA)
Gm any BUILDING DIVISION FEES
�Cenified copy is heed with the
city GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified mpyis(ikd with the city inspection dlvlalsn,
CERTIFICATE OF EXEMPTION FROM WORK ERB' GREASETRM PAID
COMPENSATION INSURANCE -
(Thissedlanneed notbecomplated lithe Permit isforone hundreddollars SEWER-SANITARY-STORM EA.MOPE. Date R. C i t#
($100)mIrse3 WATER HEATER W/VEM/FI rr.I.R ENERGY FEE Y N
Icertlfyt lathe performanceafthe� ori or hich this permit is Issued,
I shag note y any pen n b any mal tai n to bemire,subject to the WATER SYSTEM/TREATING
— Workers Com tion Lau Sof Ifs, _ PAID
C' Z APpllant NEW RESIDENTIAL PLMB. SQF[. Date Recel t#
Z O NOTICETO CAa er th ertificale of •ze tl you
should become subject to the Workers m pewtkm provisions fth Labor TOTAL:
N Code,you moat forthwith comply with Emwislom orthisN hallbe 13UILDING FEE
W C dremed maked.
CL coNsraurnoN LENDINGlea AGENCY SEISMIC FEE
]hereby aBiefoirwhat there bammwcIloed(See.ding agency 7,Civ. .) perform- .TOTAL: ELECTRIC FEE
Q Z Leads?.Nwork(or which this permit bbwed(Sec.3097,Civ.CJ
Q2 lenders Name - - PLUMBING FEE
LL F Lender's Address QTY. MECHANICAL PERMIT FEE
OW Icertifythatl have read thisappticatlsnand Matethattheabove information MECHANICAL FEE
6 Is mn¢ct.l agreeto complywith all city and munty ordinances and state laws PERMIT ISSUANCE ' FEES PAID:
>. W relatingtobulldingmrmmction,and authorize repreeentatives of this
Z .ci to enterupon theabove-manila pro rty(w lr spection purpose. ALTERQRADDTOMFCH. Date Receipt#
e)agne to eve,indemni n km harmlen the City of Cupertino -
V ag n IObNtle,' dgmenta, e n z ses whkh rreyln anywayamme AIR HANDLING UNIT 10,000 CFM) SUBTOTAL: -
aga saidcayi .sequence it soling or this p1brrnit.
AIR HANDLING UNIT(OVER IgOD)CFM) CONSTRUCTION TAX '
Sig reof Appicant/Contr ar to + EXHAU5THOOD(W/DUC'D CONSTRUCTION TAX PAID:
HAZ.ARDO S ATERIALS DI
SCLOS RE
Will theappEcant or future bu dingoccupantstore ar l nd haza a HEATING UNIT(TO 100,000 BTU) Dale RCYeI t#
material an deflsed by the Cupertino Municipal Code,Chap .12,and the -
Hr.IthandSafetyCode Section 755320)7 HEATING UNIT(OVER 100,0W BTU) ' TOTAL:
Ea
Yes No
Illtheappliamm Nmb ildingo pantuwequipmentmdevicn VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which emit haramous air mntamtwnts as defined by the Bay Area Air
Quality Management Di'strlg7 BOILER-COMP DM'OR 100,000 BTU)
4Y.sn❑No
the Mehavereadtheh.QusmaterialsrequirementsunderChapter6.95of BOILER-COMP(OVFl910 sioR[U) P A 9 D
rats Health k Safety Code,Stolons 75505,25533 and 25539.I
understand that if the bu llding don net m mently have a tem.L that it 0 my NEW RESIDENTIAL MECH. SQFT.
resporudbBity to notify the occupant of the requirements which most be oat APR 27 1992
prior to issuanm of Certificate of Occupancy.
Owner or authorlmd agent Date Igg(�pByr.,+ �M11YV
7O
OFFICE COPY