23182 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
!.Ildiog Pra ed Identification - PE tMIT NO.
Build ing Add reSs: _
G3I8G/�/� al ^ n
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a7ners NanIPhone
: t. A
CITY OF CUPERTINO-BUILDING DIVISION 1
i' Contra .awme: aTa�— - ue.No: APPLICATION /PERMIT ` rlLi Z
Architect/Engincer. Lle No: BUILDINGELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL M'
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: , PLRMITISSUANCE ❑ ❑ �SQ ❑
LIC ENSEDCONTR under SDECLARATION L�]'
IMrebyfic, 70that lent licensed under provisions a(Chapler9(mmmen APPLIANCESRESIDENf7AL JOB DESCROrTION
Ing with SectioJp�70W)of vidon3 ollhLBusineaamdProlesslonsCode,and my 6
license
"m died.kmrac G""` �.LS PANELS 90-1
Llcen `-i RC
— UP TO 2D0AhVS
Date Contractor
RCHITECTSDECLARATIONOO
aO Zp Iundentandm nseMObe used apubBc records OVEROVER 10BOAM00 AMT'S - - -SQ,FT.FLOOR AREA §/SQ.F(.
Licensed Professional SIGNS ELECTRICAL'
6 OWNER-BUILDER DECLARATIONSppCULCIgGInT,M)SC LED
LI' I herebyafflmn that l am exempt from the Conlrsdorb License law for the4PUr
pp q following reason. 70315,Business and Professions Code:An d or C
p7^ty counlywhichmqulmsapermlttommtmdalter,Impmve,de=lRh,orrepair 7LMP.METCR OR POLE INST.
L7 any rtrocture prim to its issuance,also requires the applicant for such permit to POWER DEVICES / J2 NwZ
y� T /
rt � file a signed statement that M ts licensed pursuant to the proWlans of the
�0Ow Cantndoe,License Law(Chapter 9(commencing with Section 7000)of Divi- VALUATION
abn3ofthe Businesand PreimiosCode)orthat he is exempt therelromand SSVQ.SA4NG POOL ELECTRIC'
the basis for the alleged exemption. Any violation of Section 7011.5 by any
applicant fora permit subjects the applicant to a civil penalty'of not more than OUTLETSSWITCHCSFIXTURES
five hundred dollars wnerofthe Pr). NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
7�n ❑1,ate owner al the property,or my employee with wages as their sale
k 6 compenaation,will do the work,and thestructure b not Intended or offered for
J$ ❑ sale(Sec.7044,Businessand Prolesslom Code:The Contractors License law
EI j$ doenotapply to anowner of property who builds or Improves thereon,and OCC.GROUP HIS.UNITS0.0. who docssuchworkhlmseltorthrough hisown employees,provided that such
improvements are not Intended orolfered for sale.I(,however,thebulldingor TOTAL;
impmvemcntlsmldwithlnomyearofmmplMW%the wnerbuflderwill have -
tenofpmvingthatha did nab.ild.ri.p.vef.rpurpowof vale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE nPN
nate owner of the property,am exclusively mntrading with Ilmnved PERMIT ISSUANCE
contractors to mnsVud the project(See 7014,Business and Profession Code:The Contractors License Law does not apply to an owner of property who ALM -WATER(EA)
builds or Improve thereon, and who contracts for such projects with a
c�{(ador(s)licensed pursuant to the Contractors License Law. FEE SUMMARY
I_I I'am exempt under Sec. B k P C for this mason BACK FLAW PROTECT.DEVICE
cES
Owner DRAINSSFLOOR,ROOF,AREA,CONED. SANITARY Y N -
w� Date ---
RECEIPT M
s WORKMAN I have.45ATION DECLARATION �.�S PER TRAP ^e SC11COLTAX Y N
IF ❑i hereby affirm that I have o lmum to of consent to eelbinsure,or RECEIPT al
// certllicabC.) rken'Compensatlanlnsurance oracertllled copy thereo((Sec. GAS F.A.SYSTEM-1 INCA OUTLETS PARK PER, Y N
Polis 380D,lab C.) , RECEIPT N
Policy p
Com an CAS FA.SYSI77s/-0VER4(EA)
� y BUILDING DI VISION FEES
Certfied copy ts herebyfurnished.the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE '
Certified ropybflled with the city inspection division. -
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date Recti tlt
(T'hlsaeneed rad bemmplaed lithepermitdt V(Drone hundred dation
(g10(l)orlessass) WATER IIEATER W/VENT/ELECTR ENERGYFEE Y N
Ist.oty bploythe performance oyt nnrktorwto becoepermitls tothe -
I shag not employ an a loony manner so to become subled to tM WATERSYSTRM/I`RFATING PAID
Worts C we o(Cal1(om
O Z nppll u - NEW RESIDENTIAL PLMR SQ,Ff. Date Recei tN
Z O NOTICED AI'�. Rern d gl a of Exemption,you
Hshmld bkmmesubjectt the Workers'Compensation provision ofthe Labor - TOTAL:
W Code,you most forthwith comply with such provisions or this permit shall be r
> _ deemed revoked. _ BUILDING FEE
CL G - CONSTRUCTION LENDING AGENCY - SEISMIC FEE
1 hereby affirm that there ts a construction lending agency for the perfonry ELECTRIC FEE
,n Z ance of the work for which th13 permit is lasued(Sec.3097,Civ.C.) TO
02 Lundcr'eName PLUMBING FEE
LL 1- Lender's Address - QTY. MECHANICAL PERMIT FEE MECHANICAL FEE "
OW I certilythat l have read thisapplicallonand statethal theaboveirimmallon
4 iscorrcct.lagree to comply with all city and county ordinances and mate laws PERMITLSSUANCE FEES PAID:
>. 0. tobulldingconstruction,and herebyauthatlre representatives ofthh
(_ Z • city to enter upon theabavcmentloned property for Inspection purposes. ALTER OR ADD TO MECH. Dale Recel IN
z (We)agree to save,Indemnify an d keep harmiea the City of Cupertino
against liabilities,lodgments,coetsendexpenses which may irmywayacvue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL'
- against nconsequence oft anting a(thla permit. '
AIR HANDLING UNIT(OVER IO,ODDCFM) CONSTRUCTION TAX
cant ant ct r to EKFIAUSTHODD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MAT. IALSUISCLOSU E
Will the applicant orfuture building occupant store or handle harardous HEATING UMT(TO IOO,ODO BTU) Date Remi
material as deflrud by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Cade Section 25532(a)7 - FIEATING UNIT(OVER 100,000 BTI!) IOTA '�-
F�Yes " No
11 the laxarantor arumbuilding occupantusetequipment he Bay Area device VIN'OLATIONPAN(SINGLE RESID) IGgUAN[E,J�ATE
conft Management
airrict? nb as defined by the Bay Arca Air
Y` M� 0 (�
Quality Management D'utrid2 BOILER-COMP(311P OR 1W,(Kq BTU)
❑ Yate ❑No - - JFIitl 1 `
t ihavnrei. th.itb&dfutmaterials t..255entsunderChapterG95of IK)R.ER-COMP(OV(II21W,OfgBTL1) 1992
rthc Gllfornb Flcalth k Safety Code,Sections 75505,25533 and 7:534.I
understand that lfthebuildlngdoes nacomertlyhaveatcwnL,thm It is my NEW RESIDENTIAL MECH, SQ.FE.
t reponsibaturCeity to faCereacupanto(the requirements which mull be met CITY UI' CUptHIII�
respoPTiOrtolssuance Dray the ccup Occupancy. a
..a J
Owner or authorlred agent Date -TOTAL: ISSUED BY
OFFICE COPY