21793 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification
Iiul�ldingOA.0 y, Cis /sI aI 7 9^ '
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'hm 1 !S/� one: G I 1{/
CITY OF CUPERTIN0.6UILDING DIVISION _ - O C,.
c°ntndar.N. ue.N°, APPLICATION I PERMIT C
lie "o
` sCATEGORY CONTROL N
Archlted/Engineer. Lt.No: BUfLDINGELECTRPCALI'LIJMBINGMECF1AhTCAL
QTY ELECTRICPERMIT 'FEE BUILDING PERMIT INFO
Address: PERMITISSIIANCE .DD 1:111L 1 1 El
LICENSED CONTRACTOR'S DECLARATION 4-�
Ihereby thvedion7 )ofDat I ivlicensedheunder Busiemand.of mnslmsr9(mmmme- MPLIANCESRF.SIDENRAL JOB DPSCRFFION
IngwRh Sedlon force and
f Divfect. (the Buslnessand ProfesalonsCode,and my '
LI...is in full force endd(ect. PANELS, V,Dale - Contactor - �.V •
ARCHITECPS DECLARATION 201-ODD AMPS
PQ±reO ZO- I understand my plats shall be used as public records. OVERIODOAMPS - SQ.FEFLOORAREA $/SQ.FT.
E
Licensed Professional - SIGNS ELECTRICAL -
OWNEDECLARATION
R-BUILDER
In a
zThereby afRrm thatm l aexempt from the Centrador's Llmnse LA.for the SPECIALCB2CUIT/M1SC
ppp following reason.(Section 7071.5,Business and Professions Code:An cit or
F county whm
ichmqulre.a permit to nstroct,alteq Improve,demolish,or repair TEMP.METER OR POLE INST. -
anystructum prlortu its lesuance,also requirestheappllcant(orsuch permitto
file a signed Yaterrcnt that he b licensed pursuant to the provialo a of the POWER DEVICES _
O w Coal.=License law(Chapter9(commencing with Section 7000).f Dlvl.
30 akm3 ofthe Business and Professions Code)orlhat hebexemptthercfromand SWIMMING POOL ELECTRIC VALUATION
fh ..777 the basis far the allegedexem"k. Any vialaHon a(SMlon 70315 by any
applicant for a permit subjects theappgcanl to a civil penalty of not more than OUILETSSWITCHESFIXTURES
live 1,as
demodeltathe property,
SQ, STORIES TYPECON5IRUCTION
4 µ NEW RFSTDENTIAL ELECTR Rf.
td �n ❑I,asownerll theewor",orhe eocrayeeswithwagesa their sole
or
e .1.03acompensation,0K Ihotinc New Professions
ions Code:
h not Intended or censeofferL w -
5' sale(Sec appy to anowandf property
Code:The orImproves
s License law
doesoessunot ch
wornownerofpouraghisonempoyees,povidedthat
and OCC.GROUP RFS.UNITS
0.0. whodoementsa net Intended rough hlsowale.If oweveovidedlklogor -
Improvementearenotlntendedoroftreed(orsale (he o neer-builderwitlbve TOTAL:
Improvement V sold within oneyearo(compldiory the�wner-buiWerwlll have
tl,Lkurden of proving that he did not build or improve for purpose ofsalN. QTY. PLUMBING PERMIT-, FEE FLOOD/ONE APN -
LJ{as owner of the property,am exclusively contracting with licensed
contncton to cerswct the projed(See 7014,Business and Professions Code: PERMIT ISSUANCE
`
The C.Meactorb License law does not apply to an owner of property who ALTER-DRAIN kVENT-WATER(EA)
Wild. or Improve.thereon, and who contract; for such ptaajecta with a
c' adoKs)licensed pursuant tothe Contractors Lia.Law. FEE SUMMARY
61 am exempt under Sec. B k P C for this mason BACK FLOW PROTECT.DEVICE
Owner DRAINS FLOOR ROOF,AREA.CON I. 'SANITARY Y N .
.. • Date RECEB'T.N
WORKMAN COMPENSATION DECLARATION IT)(NRES E'ER•CRAP SCHOOL FAX Y N_
pl hereby affirm that I have a certificate of consent to mif-morn,or a RECE PT M
mKifimteof Workera'Compensationlns mnmo amrtlfid copythereo((Sec:
3800,Lab CJ GAS EA.SYSTEM-]INC.p OUTLETS PARK ITE Y N
Poliry a GAS EA.SYSrEIvLOVRR p(EA) RECEIPT M
raY BUILDING DIVISION FEES
L^ertiOed copy b herebywith furnished. GREASE/INDUSIRL WASTEINTERCEPTOR PLANCHECK FEE
�Certifled ropy billeddwith the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCESE'WGR-SANITARY-STORM F.A.200177. Date Recai (#
(This section need not be completed If the permit b forone hundred dollars
(SIOD)orless.) WATER HEATER W/VENT/M.ECTR ENERGY FEE Y N
I mrtlfythat In the performance of Ne work for which this permit is issued, —
I shall not employ any person in any manner so as to become subject to the WATER SYSTGM/TREATING
Works%Compensation laws.of Gllfornla. Date PAID
O z Applicant NEW RESIDENTIAL PLMB, SQFr. Date Recei t#
JZ O NOTICE TO APPLICANT:If, ki
,after mang te this Certl(iaof Fxemptlon,you
should become subject to the Workers'Compensation provisions ofthe Labor - TOTAL:
CC O) Code,you most forthwith comply wlthsuch provisions orthb permit shall be i' BUILDING 'E
LU j deemed revoked.
CONSTRUCTION it Fa ON LENDING AGENCY SEISMIC FEE
CL .of th y affirm thatwork
thcrebsconstrodlond(Seelending agency Civ. .) perform, ELECTRIC FEE
D Z once of the work for which this permit bissued(Bee.3097,Civ.C.) � TOTAL:(-) 2 Lander.Name PLUMBING FEE
IL h IarAcesAddrcss QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW lmdlfythatlhavemadthlsapplicaWn and Yrtetbat theabove information .
IL 1.C. .Iagrce to complywllh all city and county ordinances and Yate laws PFRMITISSUANCE FEES PAID: ..
} W relatingtobulidingconslructiory and hereby authorize representatives ofthis -. -
f.. Z city to enter upon the above-mentioned property for inspection purposes. ALTIRORADDTOMFLH.
(We)agree to anve,Indemrdfy and keep harmless the City of Cupertino Date Receipt#
V against liabllllles,pd,roms,roti.and eapc..a which may inanywayaccrue AIR HANDLING UNIT(rO10,000CFM) SUBTOTAL:
ago told In ronseq .04he granting ofthis permit.
_�I AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
-81grWreo plimnt/Cantracior Dat EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE - -
Wllltheapplicantorfumm building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) -
materialasdefined by the Cupertino Municipal Code,Chapter 9.12,and the
_ Date Reeei t#
Ilealth and Safety Code Section 25532(a)7 I MATING UNIT(OVER 100,000 BTU) TOTAL: s
Ye. Ir�-,I No -
Will the appliantar(utum Jr.llding onvpart use equi proem or devices VENTILATION FAN(SINGLE RESID) , IS$�, [�J(, ypATE
which emit hazardous air contaminants as defined by the Bay Area Air w6 �
Qu lity M.nagemmtDistrld7 BOILER-COMP OHP OR 300,000 BTU)
'Ph
Yes he ❑No Q
4havercad cabb&Safet Codefabrcqul 25505, 5533 ad
of BOILER-COMP(OVER 100,000 BITJ), JAN 3
the California at lithe
k Safety Code, ofcurSection,25505ave a t and 2553t.1 _ - 14 ,• '
understand that notify
the occuing pant
of
herequir m nts tenant,that b b my NEW RESIDENTIAL MECH. SQ.FT
F 0T tolIss a c mf a Certificate
Occup.rcqulmmenb which most be rrret _ QW.
blef (M
ripe to Issuance o!a CertiOate of Ompanry. �$�r({{
Owner or authorized agent Data + of
. TOTAL: ISSUED M1_4
i' OFFICE COPY