19793 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro ed Identification PERMITEINFO
. 8ullding Address:
z z sz 4, 3 F
ners Phone: - -Yo(- CITY OF CUPERTINO-BUILDING DIVISION
APPLICATIONSU
""attoF•N.me: Lie.Na: APPLICATION If PERMITBOLDINGELECTRICALPLUMeINGMEC[iANICAL ATFCARY. A ]tet/Engineer. Lk.No:
QTY '•. ELECTRICPERMIT FEE BUILDING PE
Address: PERMITISSUANCE ❑ ❑
'LICENSED CONTRACTOR'S DECLARATION
]hereby affirm that l zm licensed under provisions o(Chapter9(commenc APPLIANCESRESIDENHAL ]08 DES�CjJRQ'�TI�OLN�•'
It...h I.fon 7000)of Dlvielan3o(the Bu.lnessand ProfosloneCode,and my /
license I. form deffect. PANELS
License Clam _ LI[.M
Date. aContraaMr
ARCHITECPS DECLARATION 701-1000 AMPS
OZO I understand my plans shall be used as pub8crecurds. OVERIODOAMPS SQ,FT.FLOOR AREA $/$Q FT. ,
Licensed Professional SICNSELECTRICAL
zo'6- OWNER-BOLDER DECLARATION
� IherebyafRreathat lam exempt fromthe Contractor's License Law forthe SPECIAL CEiCUIT/MLSC
O fo8owingretese.(Sedion70313,Busineesand Ponfesslans Code:Any city or
F� ..tywhkhrequlresapermitwcmutmc5alt-1,mp.v,demolish,orrepalr TEh1P.METER ORPOLE]NST.
$ anystmt mpriortoltsiseuanee,aIsarequlrestheeppecantforsuchper oto ({�yygR DEVICES
R`O floe a signed statement that he is Ilcensed pursuant to the provislmu of the
(Wj 3 O Contractor'.License Law(Chapter 9(commencing with SMIon 7000)of Divi- SyypythENG LEL C
a ion 3 of the Business and Professions Code)or that he la exempt therefrom and VALUATION
the bash for the alleged exem"n. Any violation of Section 71315 by any •� �.
p apEll antfora perMIeubjectstheappucinttoadviipewlty of.aran than OUTLE3SSWI� FIXTURES 70e
CCC777� fivehundreddollare(5500). NE RESID AL ELEC
❑
�n I,as owner of the property,or my employees with wages as their sole FT. STORIES TYPE CONSTRUCTION
compensadon,wllldothe work andthe structure la rot intended or offered for
O sale(Sec.7044,Business and Professions Code:The Contractor's Lireme Law
does not apply to an owner of property who builds or improves thereon,and OCC.GROIIIs RES.UNITS
who does suchwork himself orthrough his we employees,provided thatsuch
g or
Improvemsntsare notintended orofferedforsak.I(howev-rulldbuildinave TOTAL:
Improvernstabsoldwlthln oneyearofcompletlon,theowner-bulklerwit[have
tl�urde"of proving that he did not build or improve for purpose o(sale.). QTy, PLUMBING PERMIT FEE FLOOD ZANE APN
LJ I,as owner of the property,am exclusively contracting with licensed - PERMIT ISSUANCE
contractors to corstrut the project(Sec.7044,Business and Professions Code:
The Contractor's License Law does eat apply to an owner of property who ALTER-DRAW VENT-WATER
build.or improve.thonsm,,and who at,to for such Inca a wltA a (EA)
co6actor(O licensed pursuant to the Cantratar.Lkenx Law. BACK gpys,PROTECT.DEVICE FEE SUMMARY
L�I am exempt under Sec. B&P C for this reason
Owner Date DRAINS FLOOR ROOF,AREA,CON I. SANITARY Y N
❑I here WORKMAN COMPENSATION DECLARATIONRFr=#
by affirm that 1 have a cartiB-ate of caaa rt to self-Insure,or a FUTURES'PER TRA' SCHOOL TAX Y N
certificate of Warkers'Comperieatlonleamoce ora certified oopythemo((Sec. - RECEIPT N
3800,Lab C.) GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE YN—
Poliry# r 7 _RECEIPT p
Com y - CAS P.A.SYSTEM-OVER4(EA) BUILDING DIVISION FEES
❑Certliedc 4,i.hereby tumiehed.- .L' GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certffred ropy 1s filed with the city Iwpetlon ivblo8 n.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Thissetionnrednot becompletedifthe permit isforo"ehundreddollare SEWER-SANITARY-STORM EA.200FT. Date Recei t#
(5100)otifyth . WATER HEATER W/VENT/FYECTR ENERGY FEE Y N
I ceout that In the person,W anye of he wank.as I.be. subjecrmit ist
issued,
I shall not employ any person la any manner w as Ip'seroma aubjet to the WATER SYSTEM/TREATING PAID
Workers'Compeneation Lowe o(Glifornla.Date -
O Z Applicant '
Z O NOTICETO APPLICANT:If,after makingthis Certlficateof Ex con lon,you NEW RFCIDMIMAL FILMS. SQ}T, Date Recei t#
Hshould become subject to the Workers-Comperoation provisions ofthe Labor TOTAL:
WW Code,you must fMhwith comply with such provisions arthls permit shall be BUILDING •E
'> deemed revoked. ,
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
Thereby affirenthat there is a construction leadingagency forthe perform TOTAL: ELECTRIC FEE
D Z ance of the work(or which this permit b Issued(&e 3097,Civ.C.) -
V O Leader's Nacre PLUMBING FEE
LL )- Lender'.Addre.. QTY. MECHANICAL PERMIT FEE
O W Icertl(ythat]have readthbapp8catlonand statethat theabovelnformatlan MECHANICAL FEE
C incorrect.Iagreeta complywlthatleftyand county ordinances and statelaws PERMITISSUANCE FEESPAID:
} relating tobullding contraction,and hereby authorize representatives°(this -
F Z city to enter upon the above-mentioned property for hapectort purposes. ALTERORADDTOMECH.
— (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Recei t#
against liabfiltle.,judgments,coat,and-.Presse which may In any weyaecrue AR HANDLING UNIT(TO 10,"CFM) SUBTOTAL'
ag said City Inc ce of the granting of this permit.
AR HANDLING UNIT(OVER 10,W0CFM) CONSTRUCTION TAX'
r
Sigm reof Appicant/Contractor' Data EXHAUSTHOOD(W/DUCT) - CONSTRUCTION TAX PAID: !
HAZARDOUS MATERIA SDISCLOSURE
Will the apphont orfnture building occupant store or handle hazardous HEATING UNIT(TO 100,ODO BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.IZ and the
ITealth and Safety Code&tion25532(a)? HEATING UNIT 100,000 BTU) e
❑ ,Ye. . - .t��.ay, TOTAL:
No c -
• Will the applicant orYutam building occupant use equipment or devices VENTLATION PAN(SINGLE RESID) ANCE DATE
whichemlt hazardous air contaminants as defined by the Bay Area Air -
QOalftyManagementDistrict? - BOILER-COMP OR 100,0Y)BTO _ ��� 9 ) getlo
Ye. f No 1 3 IJJ
have read the haza pus materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,0(p BTU)
the California Health&Safety Code,Sections 25505,75533 and 25534.I
• understand that If the building does not currently have a tenant,that it Is my NEW RESIDENTIAL MECH, SQ.FT.
responsibility to notify the occupant of the requirement.which must be met CAIJa-�lD7T"}
prior to issuance of a Certificate pf Occupancy. f� tt��sL������y�'.'�� •
Owner or authorlead agent Date ISSUEDBV:
TOTAL:
OFFICE COPY