19554 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Rwidin Pru'ed Identification PI](MMITNO.
� /D 7.�,z .�,�, � q 19554
Owner's acre: . Ph... APPucATr077URMT7TAL=
0"G(q-4r�-y�7 CITY OF CUPERTINO�BUILDING DIVISION
c- �a— #J70�/ APPLICATION I PERMIT
BUILDING-ELECTRlCALPLUMBINGMF IIAMCAL CATEGORY CONTROL N
Archucd/Fsglncer: Lk.No:
� QTY
ELECTRIC PERMIT FEE
BUI DING PERMIT INFO
Address:Z<-C Ga /Gb_:,(:jp� C [ (fpr/ �L PFRh1IT ISSUANCE
LICENSEDCONTRACTOR'SD LARATION L 1:1 0
I hereby efflrtn lhatlam lkmsed underprovkl.ns o(Chaptcr9(commcnc
APPLIANCES-RESIDENTIAL M JOB DLSCRB'1lON
ing with Section 7000)of Division 3 ofthe Business and PmfessionsCode,and my
license Is In fur (o d effect. PANELS i
License lass&_�f Licit -s7c i� �w E�Cll-ate- -^—
Date TyContrador'7jn � , M a%/l7 r�i
ARCHITECTS DECLARATION 201-1000AMMP5
q�n as 7p I understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
k Licensed I'rolessioml SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPFCIpL CB2CUIT/MLSC
IFercby alflrmthatlam exemm
pt( mthe Conlrad.r's Lkenee law(.r the
7.O
following....(Sedion 7MIS,Business and Professions Code:Any city or all
Fzf'B c.untywhkhrcqul aper ttomwtma,alter,impmve,demlbh,ormpair TEMP.METER OR POLE INST.
anystmcmm priorto its Issuance,also requiresthe applicant fcesuch permit to POWER DEVICES
�a V file a signed statement that he Is licensed pursuant to the provlsiom of the
Dai Contractor's License Law(Chapter 9(camu ntlng with Section 7000)of DWI- SWIMMLNG POOL ELECTRIC
F OS sion3oithe Businessand ProfmiomCode)orthathe Lsexempttherefmmand VALUATION
�",•, the bash for the alleged exemption. Any violation of Section 702115 by any
OUTLETS-SWITCHES-FIXTURES
x'DCO
O appliwndred dolars($S ectsthe applkanHoa ctvil penaltydoat m.rethan
five hundreddoriesheprA NEW RESIDENITAL ELECIR PT.
I,as owner.(the roe � SI'OE6 TYPE CONSTRUCTION
p p work,a or my employes with wags ea[herr sole
compensation,willciothe
ndthestrucrom isnotintended or offered for
p dile(Sec.7ply to an o andfpropety Code:The Contractors License Law
r$ does not apply to an owner of property who Wilda orimprovsthereoq and
5^ whodoessuchwork hinslforthmugh hisownemplayees,provided thatsuch OCC.GROIIt' RIS.UNITS
i&
improvements are not Intended...!!ered for ask.If,however,the building or TOTAL:
improvement ts sold within one yea r ofeompleti.n,the owner-builderwlll have
to .den of Proving that he did not build or improve for put rpose of wk.). QTY. PLUMBING PERMIT FEE FLOOD TONE APN
LJ L as owner of the property,am exclusively rontrading with licensed PERMIT NUANCE
contract..to ronstmd the project(Sec.70K Business and Professbm Code:
The Cont.does License Uw does lid apply to an owner of property who ALTER-DRAIN VENT-WATER(FA)
Wilds or Improves thereon, and who contracts for such ptojeda with a
adorta)umnxd tmeheemt.d.r'e License Law. FEE SUMMARY
w1H°a" BACK FLOW PROTECT.DEVICE
I sr(exempt i der Sec. B n P C for this meQUTS1 DE FEES
ans DRAINS FLOOIL ROOF,AREA,CONE. SANITARY Y_ N_
Owner Date RECEII'IN
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCITOOL TAX Y N_
I hereby afRrm that I have a certificate of consent to self-Insure,ora RECEPT N
mrtiicate of Workers Compensation Insurance or a certified ropy thereof(Sec. CAS F.A.SYSTEM-11NG4 OUTLETS PARKFM Y N
Policy
N
P .e4 L�ZP7f7 RECEIPTM
diry _ GAS F.A.SYSTEM-OVER4(EA)
Cany nn.���.�.��222PPPPPP /.=NY/p• - L >17 / / BUILDING DIVISION FEES
Certified ropy it hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy
it filed withh the tM city inspection division..
CERTIFICATE OF EXEMPTION FROM WORKERS• CREASETRAP PAID
COMPENSATION INSURANCE SEVER.SANITARY-SCORM EA.200FT. Date Recel t#
(this section need not be completed If the permit Is forom hundred dollar
(St00)Or less.) WATEt IffATEt w/VEM/ELECTR ENERGYFEE Y N
I mrtify that In the performance o(the work forwhich this permit is lasued,
I shall not empty any person In any manner su s to become subject to the WATER SYSTEM/'TREATING
Workem'Compensation Lawsof California.Date PAID
Q Z Applicant NEWRESIDENTIALPLMB. SQFT. Date Recel t#
Z O NOTICETOAPPLICANT:B,after making the Certlfeate of Exemption,you
should bemire subject to the Workers'Compensation provisions olthe Labor TOTAL:
N Coda you moat forthwith comply with such provisions or this permit shall be
BUILDING
L
] deemed revoked.
W CONSTRUCTION LENDING AGENCY SEISMIC FEE •J
CL (] thereby a(Rrmthat them 6 a construction lending agency for the perform FEE
L
E
TOTAL: ELECTRIC M Z arm of the work for which this permit is Issued(Sce.3097,Civ.C.) ELECTRIC EEG
Q 0 lender's Name
U. F lenders Address QTY. MECHANICAL PERMIT FEE
O W 1certlfythutl have rcadthisapplicationaM date thaltlu.Wve Infomait. MECHANICALFEE
lsc.ingt building complywith all
andcity andhereby
countyordinancesnancsand slat claws PERMIT ISSUANCE FEES'P,AIU / •!
Y (1 city to enter upon
construction,venneandhercbyauthorin represnpurpsofthle
F Z
cityto
g.to the above-mentioned property(..inspection purposes.Cope. ALTER OR ADD TO MECH. ate Receipt#
(We)agree la save,indemnify an dim :harMess the City of Cupertino AIR HA UNIT(TO 10,000 CFM)
U against liabilities,judgments,cosbaad Asea which may in anywa attrue SUBTOTAL:
against said City lnsoNaequence of th gr.maa of this perm
AIRHANDUNG UNIT(OVER I0,(X0CFM) CONSTRUCTION TAX
0-0
S nature of AppBca t/C ntr ate IXt mubi HOOD(W/DLJCT) CONSTRUCTION TAX PAID:
HAZAR S MATERIALS DISCLOSURE
Will theapplicanto,low.building occvpsattwn,or handle havallom HEATING UNIT(TO 100,000 BTU) Date Recei l#
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the
Ilexllhand Safdy Cod ion25532(a)I -� HFATING UNIT(OVER 100,"BTU) TOTAL:
F-1Y. No
Will the applicant or lure building occupant use equipment or dev es VENTILATION FAN/SINCLE RFSID) 'ISSUANCE DATE
which emit hamnlous air contaminants as defined by the Bay Area Air
Qu Wy Management D'ipNo BOILER-COMP OIBPOR100,IXq BTIA
4Ycs No 211 t t)J
havcreadtheFa>z uartatedabrcqulrcrrcntsunder Chapter 6.950( BOILER-COMP jP11 a xS IJJ'
the California Health&Safety Code,Sections 255505,25533 and 25534. I
understand that ifthebullch dos notou noy have a tenant,that it is my N RESI DENTIAL MECII. SQFI. .4
responsibility to notify the.cmpantoft .5quircmemswhich must be ma Ci P (�IIfsPITIIIo
priors Issuance )Certificate of0 paficy i�
< WeOwner or autho ud ag e ISSUED.
TOTAL:
OFFICE COPY