19707 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prates IdemBkaion 7 PFIMTNO.
B°'r'nod 19707
r
am,: Phone: A A .
CITY OF CUPERTINO-BUILDING DIVISION
Contractors Na me: LIc.No: APPLICATION / PERMIT 2�
U r x5 BUILDINGELECTRICA4ML BMG-MECHANICAL CATEGORY CONTROL#
Architect/Engineer. Lj Llc.No:
QTY - ELECTRICPERMIT FEE BUILDING.-PERMIT INFO
Addrna: PERMITISSUANCE El ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that l am licensed under provisions of Chapter9(mmmenc APPLIANCESRESIDENT)AL JOB DESCRDTION
Ingwlth5 cion7000)ofDt"sion3ofthe Businessand ProfeaslonsCa ,and m0'
license a in fol] am and effect. C- PANELS
License Clans d Lk.#
Date -1 q ontactor (( Q
ARCHITECI'S DECLARATION 201-10DOAMPS l
0 CO I undentand my plain ahaB be used u public records. OVER IODO AMPS SQ.FT.FLOOR AR $/ .FT.
d(�
Licensed Professional
<w� OWNER-BUILDER DECLARATIONSPECLILC❑2CUIT/#LSC ' �I ,
r ' — ^ I•I�
3., Ihereby all].that r amexempt fromthe Contractor's License Law fn the
Z P following reason.(Section 7031.5,Business and Professions Code:Any city or t U-�
OGi-� TEMP.METER OR POLE INST. I-' Ttl•�
�p countywhich rcqulrcsa permittocovwct,alter improve,demollsh,orrepair t"
[5a anystructure,pdortolts issuave,aisorcquiresthe appBvntforsuch permit to POWER DEVICES /�
ad O F O file a signed statement that he is licensed pursuant to the provislow of the `y O
u, Contractor.License Iaw(Chapter 9(commencing with Section 7000)of f)m- :134 J1
SWIMMING POOL ELECTRIC L
Smog aWe3 ofthe Buulnneared Professions Code)orthat he is exempt therefromand [L VAj,1ATION
' the basisfor the alleged exemption. Any violation of Section 70315 by any
� OS appllcantfor a permit subjects the a pplleant to a civil penalty of not ore than OUTLETSSWITCHESFT
room
a five hundred dollars(SM. NEWRESIDENMALELECTR
�n ❑I,as owner of the property,or my employees with wages as thro sole SQ'FT' STORIES TYPECONSTRUCTION
F. mmpevatlogw ldotheworkandthestmRure6no tendedar offered for
^$ sale(Sec.7644,Business and Professions Code:The Contractor,License Law
e,�$ does net apply to an owner of property who builds or improves thereon,and
.. whodoessuch work himself orthraagh hisownemployees,provided that such OCC.GROUP RES.UNITS
Improvements are not Intended mattered foraale.If,however,the building or TOTAL:
Improvement usoldwilhinoneyearofcompletim,theowner-bulWerwill have
tryy¢urden of proving that he did net bond or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE
LI FLOODTDNE APN
L as owner tr the property,am exclusively contracting with licensed PERMIT ISSUANCE
Do, actors rowtonnseck Law do (Sec.7044,apply t an o and Professions Code: Z 0 D
TM Coor .Improves
License law don not apply ct f owner d property who ALTER-DRAIN k VENT-WATER(EM
Wilda or Impnrvn thereon, and who contracts ice such ptojecta with a
c tactamexmpt licensed
under
to the CantractoraLicense Law. BACK FLOW PROTECT.DEVICE FEE
OUSUMMARY
�1 am exempt under Sac. B k P C for this reason
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPT a
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SC){OOLTAX Y N
❑)hereby affirm that I have a certlfiote of consent to til(-inwre,or -ter s-V RECD p
ceniflnteofWorkery Compematfonlvuranceoraceniflad mpythereot exe. GAS EA.SYSTEM-1 WCAOUTLETS PARK FEE Y N
3800,lab C.)
Policy# RECEIPT#
Com any GAS EA.SYSTEM-0VER4(EA) BUILDING DIVISION FEES
Certified copy 6fil famished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCI IECK FEE
Certified copy is fliedd with with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Recel t#
(I'a,Ins.) need red be<ompicted if the permit is(Drone hundred dollar
(5100)orlessJ WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I llnot that In the peps n nce in an mewwkw for
as towhich becam permit
subj cowed,the —
I shall not employ any person In any manner eo n to become subject to the WATER SYSTEM/TREATING
Worlicri Compenatlon laws of California.Date PAID
z Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Recei t#
Z O NOTICE TO esub)CAM:If,after making pos Certificate of Exemption,you
H N should become subject to the Workers'CompevaHon pmvisiov of the Labor TOTAL:
Cade,you most forthwith comply with such provisions or this permit shall M
2 9 dinned revoked. BUILDING FEE
W C CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Ihereby affirm that hem is a construction lending agency for the perform- Togal: 0. ELECTRIC FEE
U7 Z arm of the workforwhichthiapermitisIssued(Sec.3097,CIv.C.) PLUMBING PEE O•
O Lander.Name
LL H Lender.address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icenify thatl have andthisapplivtionand slate thattheabove information
1 isrorrctt.lagrety
etocomplywlthalieand countymolinances and state laws PERMIT ISSUANCE FEES PAID:
>. relating to building construction,and Mreby authorize representatives of this
Zcity to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMF-CH. Da[e Retef [#
V _ (We)agree to ave,Indemnify an d keep harmless the City of Cupertino P
against liabilities,Judgments,cost.and expenses which may in any way scion, AIR HANDLING UNIT TO 10,000 CFM) SUBTOTAL: 410� �
agaW aid City in consequ ence pflM granting of this permit.
!— � s �/� C7 AIR HANDLING UNIT(OVER 10,000CIM) CONSTRUCTION TAX
Slg ppjfs c nt/Contractor Date IXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a ppBvnt or future building occupant store or hared to harardous HEATING UNIT(ED 100,000 BTU) Date Recei tic
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
I ealth and Safety Cade Section 25532(a)7 HEATING UNIT(OVER 100,000 BTIJ) TOTAL: d_d0
❑ Yes No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSIIAN(9:T1A'J'E
which emit haeardou air contaminants as defined by the Bay Area Air PAAiRrVS
Quality Management Dbtnct7 BOILER-COMP QHPOR 100,000 BTU)
4Yea
ha crnleadthe h.9usomaterials requirementsunder Chapter 6.95of BOILER-COMP(OVER 100,000 BTU) yrs 1 q 1990
the Califoia Hnllh h SafetyCode,Se tow 75505,25533 and 25534.I
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ-ET.
responsibility to notify the occupant of the requirements which most be mct �`• �T
priortoissuanc,of a Ce ificateof Oceupsnry. VN' of rc�
thmiaed agent Date TOTAL: ISSUED BY: -j vL KV
OFFICE COPY