20999 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pru'eM ldendfioHo^ 7 PERMIT NO.
Building Address:
ilo$ ZZ-NIS f-6n.D 20999
+ 1 ' /// one: A A
C - S �1N 'y Y� •"2.�$'� CITY OF CUPERTINO-BUILDING DIVISION
• Contractorpp'aNa •--� see. o: APPLICATION /PERMIT
S '1 BUILDINGELECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL
Architect/Engineer. Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address
PFAhOTISSUh NCE ❑ ❑ ❑
LICENSED CONTR under provisions
RATION
Ihereby ion70 shall ivsionsed 3.ftheerinessaomo(Chapter ssions9de,and c- APPLIANCESRESIDENITALing JOB DESCRIPTION
Bonn.
I.
top0)af Division o(the Business and ProleaslonsCode,and my
license b in fuB d effect 9 PANELS GH-�x � vv-
LlcenuClay an Lie.M Z- 1 O
Date O iz ui;toUP TO 200ANTS
ARCHITECT'S DECLARATION OV201-1000 AMPS
2 I understand my plana shall be used as public recorde ER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
o
OC
o(s Licensed Professional SIGNS ELECTRICAL
661 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MLSC
yes"' Iherebyaffirm'hat I am exempt from the Contractor's License Law for the
following reason. an 7mlS,Buelnem and Pm(emlons Code:An tl or
O E'u9 cou atywhich required a permit to coraHut,alter,improve,demolish,or repair TEMP.METER OR TOLE INSf.
`'� C�i any structure prior to its Issuance,also required the applicant for such permit to POWER DEVICES
file a signed statement that he Is licensed pursuant to the provisions of the
m Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
H O sion3ofthe Buslnesdand PM.Wio CWe)arthxe
athehemptthemfmmand VALUATION
the basis for the alleged exemption. Any Violation of Section 7031.5 by any I r
¢5 aPph..tfora pecord.ubjecta the applicant to a civil penalty of not more than OUTLETSSWITCHESD[TURES
dred
a five 1, aownerof thepr. NEW RESIDENTIAL ELECTR STORIES TYPECONSTRUCTION
j.- ❑I,as owner l of property,or my employes with wage as there dole �'�'
compensation,,wflBusiness aworkfmionand the structurebnot intended o ioffered naseLfor
O vie($ec.9014,Business Pro(eslore Code:The Contrattor'sUceme law
dos not apply to an owner of property who Wilds or improves t hereon,and
a who doessuchwork himselfmthrough his own employees,provided that such OCC.GROUP RES.UNITS
Improvements are not intended oroQered for sale.If howevegthe bulli ng or TOTAL:
improvement Iswld within oneyearofcompldioM the owner-builder will have
the hardenofproving that he did not build crimprove for purpose ofsale.). QTY. PLUMBING PERIviIT —• i FLOOD ZANEu APN
I_I I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to cerestrud the project(Sec.7044,Business and Profesima Code: I '
MContractors Llrense Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER&JU
d or Improves thereon, and who contracts for such plojetts with a
FZ
,,N
WIctor(s)licensed-Me,
to the Contractor's License Law. BACK FLOW PROTf:CT.DEVICE UMIN RY
LJ 1 am exempt Sec. B 6s P C for this reason
DRAINS FLDOR ROOF,AREA, SAMTARY—Y----N'�"'
• Owner ECLDat — RECEQ9,a
WORK MAN COMPENSATION DECLARATION FIX'IURF_S PER TRM SCHOOL TAX Y— N—
❑1 hereby affirm that I have a lmurane od consent to py tnsure,or RFCEBT if
certifl1.b C.) orken'CompevaHonlrouranre ora certified copy thereof(Sec. GAS EA SYSTEM-1 INCA poli Lab CJ PARK FFP Y Npol —
Com any CAS EA.SYSTEM-OVER4(EA) BUILDIf INGGDDIVISION FEES
�Certlfied copy is herewith the eil.city CREASEANDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
❑Certified copy u filed with the city Irape tion division.
CERTIFICATE OF EXEMPFION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANTEARY-STORM En 20BIT Date Recei t#
(phis cession need est lecompleted tithe permit b(Drone hundred dollars
(810 mdifys.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I cent that o any person nce of in any m wwkso si,to h this permit Is Iso theed, —
I shall rs employ any person In any manner w s to became subject to the WATER SYSTEM/TREATING
Workers Compensation Lawn alGllfornla.Date pplp
O Z Applicant
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
shwld become subject to the Workers'Comperaatlonprovislov of the Labor TOTAL:
N
Once,you=at forthwith comply with such provisions;orthb permit shall be
> dermad rewked. BUILDING ••E
W CONSTRUCTION LENDING AGENCY SEISMIC ITE l
CL Ihereby affirm that mere Is a construction lending agency for the perform- ELECTRIC FEE
7 = anccuf the work for which this permit Is issued(Sec.3097,Civ.C.) TOTAL:
U O Lender's Name PLUMBING FEE
U. F Lender;Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W IrerUfythatlhavemadthiaapplimtionandtatethattheaboveinformatlon
Isomer.Iagreetocomplywlthallcityandmuntyordinanmsand Aatelawa PERMIT ISSUANCE FEES PAID:
relating to building coustrution,and Mrebyauthacarreprsentativesofthis
I--' Z cltytoenterupon axwv nsentloned property for inspection purposes. ALTTRORADDTOMECH.
(We)agm to Indemnify an d keep hzrmleas the City of Cupertino Date Recei [#
V agalmtlbbBit menta,cosy and expenses which may In anyway acme AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL:
against said Ci nsequence of the granting of this permit.
AIR HANDLING UNIT(OVE410,0DOCFM) CONSTRUCTION TAX
s o p cent/Contractor I Ina EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSUR
Wlllthe applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)) Date RCCeI t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I ealth and Safety Cn 75532(a)7 [BEATING UMT(OVER 100,000 BTIJ) TOTAL:
❑Ys
Wllitheapplicant future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
whichemithazardoi ir contaminants as defined by the Bay Area Air
Qualhy Maiagcment Mt7 BOILER-COMPOM'OR100,00HTU)
4Y. ppppppRIP��
havcreadthehaza o oateriabmquimm nbunder Chapter6.95of BOILER-COMP(OVER 100,000 BTU) r/ M
the California Health h S. Code,Sctlora 25505,25533 and 25534. I
understand that ifthebu does not currently have a tenant,that it Is my NEW RESIDENTIAL MECH. SQ.FC `�Y-
rp'TODD
reiporoibility to notify pant of the requirements whit mus be nM ,9`� E IJ.a
poor to issua ceof if teof Occupancy. s9
Own or hurt' d t �j Pate C"
TOTAL: ISSUEDB
OFFICE COPY