22084 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: ^n O 8 A
oars _/ ' 1 G G V{ 4
Jn V(,//SOL •yy 6- 9?p CITY OF CUPERTINO�BUILDING DIVISION _��
centraaor'.:/yName: LIe.Ne: APPLICATION / PERMIT
t d - CATEGORY CONTROL X
BUILDING-ELEC77UCALI'LUMBING-M[CHAMCAL
I A ilea/Engineer. _ Lie.No:
QTS' ELECTRIC PERMIT FEE BUILDING PERMIT INFO,
Address: PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ahereby affirm that l am licensed under provisionsu(Chapter 9(commmc APPLIANCESRESIDENTIAL JOB DESCRIPTION
Inenseiinf Jvfect. o(the Buel aged Pm(avlaneCode,and /
Ilcenx le In(uB ace and effect. ` PANELS
Data Class Lie.M / Z / 17
Data/y�7. 9— UP TO 200 AbliS
9C Contractor . 201.10130AMPS
')(�
ARCHITECTS DECLARATION
070. I understand my plan shell be used as public records. OVER 1(00 AMPS SQ,FT.FLOOR AREA $/SQ.Fr.
Fa� Licensed Professional - SIGNS ELECTRICAL
<6
OWNER-BUILDER DECLARATION
SPECALCIRCUIT/MISC '
a•rJ,� Iherebyaff,.that lam exempt from the Contractor's License Law forthe
7o following reasan.(SMlon 7011 S,Bueincn and Proleulons Code:Any sty or
O Z H TEMP.METER OR POLE INST. epoi —4
r� county which rcqulresa pemdt tocoruwct,alter,improvq demollsh,or repair '
g anystructure pdortolta batteries,also requlrestheapplanl for such peormtro POWER DEVICES
ES fill a signed statement that he b licensed pursuant to the provlslmx,of the
3" Contractor'.License Law(Chapter9(commenangwlthSection 7D00)ofDivl-
0 SWIMMING R70L ELECTRIC
the b ofthe Business and exemption.Code)orthathe f exempt therefrom and VALUATION
ydS
the basis fortheallegedexemption. Anyviolationtolacivi ofSectionno
re any - C V .
ff appllantfare permit eubjectstheapplicanitoaavll penalty afoot morethen OUTLETSSWITCH[S17XTURFS
live hundred delta.($500). NEW NFSIDENTIAL ELECTR__BQ,FT. '
❑I,as owner of the property,or my employees with wages as their sok FS TYPE CONSTRUCTION
compensation,will do the work and the structure isnot Intended or offered for
O sale(Sec.7044,Bu.Ine.s and Prafeulmu Code:The Conametoes License Law oe
$ doesnotapply loan owner of property who builds or improves thereon,and OCC.GNOIIIs RES.UNITS
whodoes suchwork himself erthmugh hlsownemployees,provided that such
Improvements are not intended oroffered ferule.If,however,lhebuilding or TOTAL
Impmvemcntlsxldwithin..eyxarofcomplaioe,th owner-bullderwlllhave
tl urden of proving that he didnM build or Improve for purpose of sale.). QTy, PLUMBING PERMIT FEE FLOOD ZONE APN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE'
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds of Improves thereoe, and who contracts for such pr -
ojee s with a - FEE SUMMARY
cob.cor(s)Bcenxdpuvuanl to the Contractors License Law, BACK FLOW PROTECT.DEVICE
II._II I am exempt under Sec. B& P C for this reason
DRAINS FLOOR ROOF,AREA,OOND. SANITARY Y N
Owner Date RECEIPT a
WORKMAN COMPENSATION DECLARATION FXTURFS PER TRAP SCJ{ LTA% Y_ N_
01 hereby affimloer that I have• Inst a c of consent ro opythsurc,ora RECEIPT'M
38ML.1,dificate o(Workers'Compewtion Wuranceoracertllled copythereo((Sec. CA EA.SYSTEM-1INC.40U1LETS PARK FTS Y N
RECT3800,Lab C.)
I'vllryM 6 2�Cam ip
iS M-
anY _ka GAEA.SYSTEOVER4(PA)
BUILDING
DIVISION VISION F[E$
[aeertlfleacopy
. re
.acenlned ropy is filed withthecity Irmpeamn division. - CREASE/INDUSTRLWASTE INTERCEPTOR PLANCHECKFEE
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA 20OFl• Date Recei t# '
Qhis section need ria M completed If the permit b fmox hundred dollars
(5100)°ales') WATER HEATER w/vFNr/¢FGTR ENERGY FEE Y N
I certify that In the performance of the work lOrwhich this permit is loved, —
1 shall not employ any person In any manner n as to become subject to the WATER SYSTIIDI/TREATING
Workers'Compensation laws of California. Date PAID
z Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. r Date Recei t#
Z O NOTICETO APPLICANT:If,after,making thisCertlflate of Exemption,you
Hshould bemme subject to the Workan''Compematlon provblom of the Labor TOTAL:
cc N_ Code,you moat forthwith comply with such provisions or this permit shall be B G l
W D deemed revoked.
CZ
O. F3 CONSTRUCTION LENDING AGENCY SEISMIC FEE C
I hereby affirm that there b a coutmaion lending agency for the perfamm - ELECTRIC FEE
7 Z ante of the work forwhichthls permit b Issued(Sec.3097,Civ.CJ TOTAL:
_V.O Lcmiaes Name PLUMBING FEE
LL F Iandcea Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW 1mA]fylhatlhavemadthisapplimtionandatatethattheabovelnformution
CL Iscorrca.I:greetocomply with all city and county ordinance and agate laws PERMITISSUANCE FEES PAID:
>_ W relatingwImildi.g mmtructimi,and hercbyaux
thimacroprenlalivesefthis
Z city to enter upon the abovo-mermioned property for Inspection purposes. ALTER OR AUDIO MFiCH. Date Recei t#
_ (We)agree to save,indemnify an d knep harmless the City of Cupertino P
ag.lost liabilities, costsend expenses which may In anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) - SUBTOTAL:
against al Ity I/n�cyy�ppsequence of the granting of this permit. -'
AIR HANDLING UNIT(OVER I0,000CFM) CONSTRUCTION TAX
`
Signa of ppRa Date EKHAl15'T HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS
MATERIALS DISCLOSURE
Wlllthe applicant orfuture bulldingeccupant store orhandle haaardous HFA71NG UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I ealth and Safety Code Section 25532(a)I HEATING UNIT(OVER 100,000 RM TOTAL:
❑Yu u NO
Will theappltael car futurebullding oavp.ntuae equipment ordcvice. VENTILATION EAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management Distrkt? 1 BOILER-COMPD11POR 100,000 BTU) -
t i Yee ❑❑un _ IMAD ,
4h3vereadthefiazallouemalerialarequlremnbundcrChapler6.95of BOR.E2COMP(OVER100,000BN) .
the Ca II(omlz Health It Safety Code,Sections 25505,75533 and 25534.1
and creta nd that if the building does not currently have a tenant,that it b my NEW RESI DENTIAL MECH. SQ.Ff.
responsibility to notlN the occupa nl of the requirements which met ^� 4T ❑ �QQ'I
pnorloW nese rtiflcateof Ocxvpancy. r 9 ✓ 09
���_ y^29
Ow or aulhodzed agent Date lMR m, x
TOTAL: ISSUED BY:�I �� YY--
OFFICE COPY
r