19941 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES'—'USE BALL POINT PEN ONLY
Building Project Identification PEILMIT NO.
Building Address:
so�� 19941
ere scot: Phone. -
n:c.�nolol CITY OF CUPERTINO-BUILDINCDIVISION '
Cr"arswme: u..No - APPLICATION / PERMIT
n a `� CATEGORY CONTROL' Architect/Fsglneer. vJ LIaN OU1LDiNGELECTRICALI'LI)MBINC-MFCHAMCAL"-
'98 moo` QTY ELECT RICPERMIT 'FEE BUILDING PERMIT INFO'
Address: PERMITISSUANCE ❑ ❑ ❑
LICENSEDCONTRACTOR'SDECLARATION
I hereby affirm 11011 am licensed under provisions of Chapter 9(mmmrn APPLIANCESRESIDENTIAL -JOB DESCRIPTIONm
IngwllhSed1on 70N)oIDINYon3of1he8uelnes^C.ode,and my �;��
Ilcenis in fu fo tidied. V`GPr, PANELS
License Cla Lic.p ` a,
Date - Comrades rk W as'ba^
ARCHITECPS DECLARATION701-1000AMP5
ce0 Z 'I understand my plana shall W used as public records OVER 7000 AMPS , oo SQ.FT.FLOOR AREA .$/SQ.FT.
. O
Licensed Profemibrol SIGNS ELECTRICAL 1 Lm E ® IN
j
I
6� OWNER-BUILDER DECLARATION °n•a IR - SI'F.CIALCE(C OR/MLSC YTER
Z 1..,YAa 1herebya(Rrm Chat!am exemp[Irom Ne Contractar'e License Law for the
pp following reason.(Seclion 7071S,Business and Prefesions Code:Any city or f••
O Z p. TEMP.METER OR POLE!NST,
K cwntywhkh rcqubesa permNtomrotruct,alter,Improve,demolish,or repair. -
anystructurepriortoitsissuance,also requires the a pplIant for such permit la POWER DEVICES' � /Z
O file a signed statement that he is licensed pursuant to the provisions of the _ 43
.3 u, Contred.e.Liceroe Law(Chapler9(mmmencingwithSedlon70W)o(Divi-
�fSOSIn SWIMMING POOL ELECTRIC
O
don3oftheBusInese and Pro(esloroCode)orthet he Vexemp[therefromand � VAC•] the basis for the alleged exemption. Any violation of Section 7071.5 by any OUTLETSSWITCHESFIXI'URES
applicant fora permit subjects the applicant to a civil penalty of nae morethan
five hundred delta.(S500). a NEWRESIDENTIALELECTR_SQFf: STORIES TYPE CONSTRUCTION
❑I,as owner of the property,or my employees with wages as their sole
7Q compensation,will do the work and the structure is not Intended or offered for
D sale(Scc.7044,Business ami Professions Code:The Contractors License Law
dos not apply loan owner of property who builds orimproves thereon,and - OCC.GROUP RFS,AMTS
whodmssuchwork himself orlhrough hisownemployees,provided thatsuch
Improvements are not intended oroffercd forsak.I(howevegthebuilding m TOTAL:
Improvement ksoldwilhinoneyear.!compidion,lheowner-bullderwlllhave
Ileno(proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT "FEE FLOOD ZONES APN
L L a.comer of the property,am exclusively contracting with licensed PERMIT ISSUANCE'
contractors to coratruetthe project(Sc.7044,Buelnes and Preleslom Coder
no Contrsdofs License law does net apply to an owner of property who
Wild.or Improves reon,theand who contracts for such pt jecei with a, ALTER-DRAIN k VENT-WATER(EA)
"�pl[+ctm(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
IJ f am exempt under Sec B h P C for this reason ' OUTSI DE FEES
DRAINS FLOOR,ROOF,AREA,GOND. SANITARY ,Y N
Y;. Owner Date RECEIPT a
WOR10.tAN COMPENSATION DECLARATION FIXTURES TRAP $C71001,TAK Y - N
1 hereby affirm that 1 hrve a certificate of consent to pythemof(Sa RECEIPT 0
certlflI I,C) orken'Comperoatl(nlrouranre ora certlf4d copylhereof(Sec. GAS EA.SY9TEM-1 INCAOUTLETS PARK FEB Y N—
P.)
P.)I38W lI ��1��. ��1��'������... ___aaa��� .� r�
Pollry prs'i_P s�' A £tV P l� - RECEIPT M ,
CAS FA.SYSTEM-OVER 4'(EA)
Camay a 107/ GNfS BUILDING DIVISION FRES
ettlBed cop Is CertlRed copy V filed with the city hercbytumcity ty inspection division. GREASE/INDUSML WASTE INTERCEPTOR PLANCHECK FEE
• ,
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORMEA200FT Date RCCCI tp
Rhlss. naed rad Wcamplcted If the permit kforonehundred dollars '
E$100) NIssuWATER HEATER W/VENT/ELECTR ENERGYFEE•
les.)
I .)certllythae lathe performance o(thework(orwch this permit is
ed, Y_ N—
I shall not employ any person In any manner se as to become subject to the WATER SYSTEM/TREATING Workere Compensation Laws of California.Date PAID .i
.Z Z. Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Remi tit
Z O NOTICE TO APPLICANT.If,after making this C.niflate of Exemption;you
should become subject to the Worker'Compensation pmvlsloro of the Labor TOTAL:
(/) Code,you must forthwith comply wRhsuch provisions orthb permit shall be
> deemed revoked. BUILDING FEE
,a CONSTRUCTION LENDING AGENCY SEISMIC FEE _
I hereby afOrm that there le a mrotruction lending agencyfor the pedom,
7 Z anceofthewmkfor whichlhispermit kLssued(Sec.3097,CIv.C.) TOTAL: ELECTRIC FEE
O O Lender.Name - PLUMBING FEE'
ILH IArdcr.Addm.s QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW 1 certifythati have read thkappliationand statethatthe.bovs information
IL iscomud.I agree to complywith all cityand county ordinances and date laws PFRMIT ISSUANCE,.. FEES PAID:
} W relating to building construction,and hereby authorize represcntativca of this ,
Z city to enter upon the above-mentioned property for inspection purposes, - ALT FR OR ADD 70 MECH.
(We)agree to ave,indemnify an d keep harmless the City of Cupertino -, Date Receipt#
V against 5defincd
oreal., ed expenses which may in any way... AIR HANDLING UMT(TO 1Q000 CFM) SUBTOTAL:
againstn a she grant ing ofehlspe ,
"�' �� 9 AIR HANDLINGUNIT(OVER IQMOCFM) CONSTRUCTIONTAX
/ tractor D = EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
-HAZARDOUS MATERIALS DISCLOSURE
Willor future building occupant store orhandle hazardous HEATING UNIT(TO 100,000 BTU) Date RCCCI tic -'
tcrl. the Cupertino Municipal Code,Chapter 9.17,andthe
Tleallh and Safety Code Section 25537(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
Yes No
Wllltheappliant or uturn building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) - ISSUANCE DA'Z'E -f
which emit hazardous air contaminants as defined by the Bay Area Air.
Quality Management DisMn9 BOILRR-COMP QHP OR 100,0110 BT1n p�
Yes he I�No P
haveread Health
ardours materiahriImi25-%5, 5S33aChapler G95 of BOILER-COMP(OVIR 100,0170 BTU) O
the Crstilt Health&SafetyCod.,Sections75505,ve a teaad75514.1
usponsindytohat lfthebheocupart net mrrentiyivero each that eBmy NEW RLSIDPNIIAL MECH. SQ.IT JU{, � 0���
rrspr to ices lty t°notify the ocmpant of the requbemenb which must h.met ti
prior to lsuance o(a Certificate ofOttvpanry.
Owner or authorized agent Date
TOTAL: ISSUED
B \Cl•
OFFICE COPY.