20544 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
°7y6_�° - 20544
aA A
N ane CITYOF CUPERTINO-BUILDING DIVISION p �D
Contra Name: / Lit.No: 7 APPLICATION I PERMIT o
e - G/O'- eZ / BUILDINC-ELECTRICALPLUMBINGMECHANICAL CATEGORY CONTROL#
Architect/Engineer. Lie.No:
QTY ELECTRIC PERMIT )FEE BUILDING PERMIT INFO
Addmss PERMIT ISSUANCE /`-�� ❑ k ❑ ❑
LICENSED that ED CONTRACTOR'S DECLARATION
I herebyScctioirmihatlam licensed ofthe uMnesssiomsofoodoner9(mmmmc APPLIANCES JOB DESCRIPTION
ingwbh in fom7000)OfDivlsion3 ofthe Bualnnsand pry/esionsCode,and my
license is In full fora an effect PANELS �
License lass Licp �I
Date Contractor UP TO 2DO ANIPS
-
ARCHITECI' CW TIO 201.1000 AMPS
ctO Zp ]understand my pisco shag be used as pe ds. OVER IOJO AMPS SQ.FI'.FLOOR AREA $/$Q.FT.
Fi o Licensed Professbml SIGNS ELECTRICAL
< _ OWNER-BUILDER DECLARATION $PECIALCI2CUIT/M15C
7s- / (hereby affirm d
that l am exempt the Contraor'sLicense Law for the
following reason.Section 7031.5,Business and Professions Code:Any city or
Pill I cmntywhiamqulresapermlttommtmct,alter,im TEMP.METRR ORPOLE(NST.
prove,dernobh,ar repair
$ 6 anystructure priortohateme its that
he is also icamed pursuaneathe t
to the fwsuch ions of it a POWER DEVICES
Q 3 floe a signed statement that he t licensed pursuant it the provisions of the
q A..Con3ftheLiceme Lw 1.1fe drsCodo)(commencing with Section7000) Diel-
A..
ivi- SWIMMING POOL ELECTRIC
O slon3o(the Buslnesand Profemlam Code orthat hebexempteherefromand VALUATION
the bash for the alleged exemption. Any violation or Section 70315 by any
p<�
applicant fora mit subjects theapplicant to a doll 1 of net more than OIITLETSSWHCEIFSHXTURFS
e fPP per Kpenalty -DD
c. five hundred douse(x500). NEW RESIDENTIAL ELECTR
6 ❑1,as owner of the property,or my employees with wages there sole e'PQ'ET STOW 6 TYPE CONSTRUCTION
compewt044.wW Bothe work andihe etmdure boot Intended or License
L for
$ ❑ sale(Sec apply Business and property
Code:The Contractors Liame Law
(� $ dim not apply m an owner or property who builds or Improves thereon and OCC.GROI .
whodoeseuchworkhimsellorihraugh hisownempmployee,providedthatsuch RESUNTrS
Improvementsam not Intended orofferect!orsals.If,however,thebuilding or TOTAL:TXO
improvement issold wilhinoneyearofeumpletion,the owner-builderwlll have
th,a-Ilurden of proving that he did not Wild or improve fou purpose of sale.). QTY. PL ING PERMIT
LJ I,as owner of the property,am exclusively contracting with licensed E E7.00D ZDNE APN
connectors to construct the project(Sac.70K Business and Profenlom Code: H
The Contractor's License Lw does not apply to an owner of property who AL RA WATER MA)
or improves thereon,and who contracts !w such inniem with a
cgn_t�admit)licensed pursuant to the Contractor's License Law. BAIX W T. FEE SUMMARY
.I_I I am exempt under See B &P C for this mason
Owner Date DRLLS
AI ROOF, ND. SANI'T'ARY Y_ NnIlTqI �
• WORKMAN COMPENSATION DECLARATION RECEIPT#
❑1 hereby affirm that I have a certificate of consent to seI-insure,w a PER SCHOOL TAX Y N
mniflab o(Workers Compcmatlon Wuranaora certirled copy lherrof(Sec. RECEI'f#
Ivicy#b CJ .SYSTEM- 5 PARK FEE Y N
Polity Y —
C��-a���m111PPPany E.A.SYSTEM-0 4 ) RECGIPI'#
edified copy b hereby th e d. BUILDING OI VISION FEES
a� rtl(icd copyblllcd south ththe dtiny Wpectlon dlvielon. GSKASE/lNDUSTRL WASTE INTERCEPTOR PLANCHECK PEE
CERTIFICATE OF EKEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Thlsseefonneea not becompleted lfthe permit bforonehundreddollars SEWER-SANITARY-STORM EA.200F1', Date Reuel t#
(510 codify that
WATER HEATER W/VENT/ELECTR ENERGYFEE Y N—
I
emanon the parsmanan thewwkso as tobthbpemnitcbo the _
I shall not employ any person In any manner at e to become subject to the
Workers Compensation Lwa o(Gllfomb.Date WATER SYSTEM/TREATING PAID
O Z Applicant
Z O NOTICETOAPPLICANT:ILaRermaking thisCcrtifiateor Exemption,you NEW RESIDENTIAL PLMB. SQ,FI'. Date Remi t#
Fshould become subject to the Worken'Compe—if-proolid..of the Labor TOTAL-
Coca,you=at forthwith mm Ply wlthsuchprovblomorthbpxmdtAaIIW
W > deemed revoked. BUILDING FEE
d o CONSTRUCTION LENDING AGENCY SEISMIC FEE
7 Z
(hereby affirm that them is a mmtmction lending agency for the perform TOTAL: ELECTRIC FEE , o
arcs of the work for which this permit b Ltaned(Sec.3097,Civ.C.) 0.
U O
Leader'.Name PLUMBING FEE
tyF Lnderendareas QTY. MECHANICAL PERM tT FEE
O W Iartifyihat]have read Nbappllation and statethatthe above inlormatlon MECHANICALFEE
- ,
1 bcorrect.I agree in comply with all cityand countymefinanos and state laws PERMIT ISSUANCE,,' FEE—PAID:
N relating toWilding construction,and hereby authorize mpresentativesofthis
F- Z city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH.
V - (We)agree to ve,Indemnify an d keep harmless the City of Cupertino Date Receipt#
agaimt llabiBI ,rydgmenb,m a expense which may in any way accrue AIR HANDLING UNIT(TO 10,000 CFM)
agalmlaal yin comeque o! egvnting of this permit. SUBTOTAL: _
6 AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
- Sig reo ppOcant o era r Date IXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA RDO S MATERIALS DISCLOSURE
Willthe applies mfu building cmpant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
nrotr alasdcfi bythe upertino Munidpal Code,Chapter9.l2,andths Date Recel tit
Fleallh and Safety Code Section 25532(a)7 Ye HEATING UNIT(OVER IDg000 BTIA (]
Will the appliaf]No TOTAL:
nf orfuturc Wlldingompant use equipment ordevices VENTILATION FAN(SINGLE RESID)
which emit ludefined by air contaminants as defiby the Bay Area Air ISSUANCE
,-�1
Quality Management District? M00,0W
,0(q BTU)
Ye No
'?
havee ardous materlab mqulrcmenta under Chapter 6.95 of COMP BTU) 41 t's� V -I�C.;I&SafetyC tom 7550.5,75533and 2!iSM.IJ V .JVhe bullous oes not rrcnlly have a tenant,thaf it L'my . SQ.Ff.oUf'the pant oft erequlrcmenls which must be rraM /s
ofaCertifiacof c anCt efCupertino
zed age ate ti /"s
Fil TOTAL: ISSUED BY:
OFFICE COPY