20798 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
eai4 d a l✓ PY.�l( pv�re 20798
r/0/yJ �/Jf 73p CITY OF CUPERTINO-BUILDING DIVISION
Contractor.Name: Lie.No: APPLICATION /PERMIT
BUILDING-ELECTRICALI'LUMBINGMECHAMCAL CA CONTROL
A ItC/Fsgi r oyA G 2/ kN0. QTY ELECTRIC PERMIT PEE BUILDING PERMIT INFO
Add.: ,W fi-e�jlr".S'I: ,,�J I PERMITISSUANCE �-Qb Ig 1:1A�--��{
LICENSED CONTRACTOR'S DECLARATION
I hereby affmo that l am Bcenaed under prwksiosis of Chapter 9(comment APPLIANCESREMDENIAL JOB DEM`TION
Ingwlth Secttoo7000)of DiWslon3 ofthe Businessand ProfesslonsCode,and my
license is In full force and effect PANELS
Llcenx Chas Lic.It [ham r` �\
Data Contractor 2011000 AMPS •
ARCHITECTS DECLARATION OVER IODO AMPS SQ. FL AREA $/SQ.Fr.
�Q'CZ ] sed rsuindprofessional
my ional shall be used as public records, 36 �.
U(0
Licensed Profesabvl SIGNS ELECTRICAL
OWNER-BUILDER DECLARATIONlhereSPECIALCEZCUIT/MISC
f., owing reason.
7MI.mptfroessa ContneoionsCoe:law fort he /s�NA 1 1
z9I_ following don. se tion 7mL5,Business and Professions Cade:Any etlyorTEMP.METER OR POLE INST
OLl-� countywhi&requbeapermlttomnstmc,alter,impmvedea 16h,or repairir
KyQ� anystmcture prlorto Its Issuance,also requlresthe applicant for such permit to MWER DEVICES
file a signed statement that he V licensed pursuant to the imc itions of the
Contractor's License (ChapterLaw 9(commencingithSection 7000)ofDlvi-
3:8slon3ofthe Businesdand Profelov Code)orthaheisxemptthemfmmand SWIMAIING POOL ELECTRIC VALUATION
El Sn S the basis for the alleged exemption. Any violation of Section 70315 by any
O OUTLETSSWITCHESFIX TURFS b L
EF Q appllondred dollars subjects the applicant toa Avil penalty of not more than
R C`u fivehundreddoofthe 00). NEW RESIDENTIAL ELECTR O STORIES CONSRtUCTION
IIkCn�sltI 1 owner of the property,or my employees with wages r their dole /
%� sale(Sn.7044,will do Husionthcworranathestmdc:TheCure 6 ntractIntendr'orcense,d for
Law
y�� vie(Sec.7044,Business and Professions Code:The Contractors Lirense law
SrQ does not apply to an owner of property who be lids or improv ,
es themeand OCC.GROUT' RIS.UNITS
T- whodoeasuchwork hlma tforthrough hisownemployees,provided that such �e,V
Improvements arc not Intended oroffered for sale.If hmvevegthebullding er TOTAL:
Improvement b sold within oneyearafcomplello,the awner-buMerwlll have
t4l4urden of proving that he did not build or lmprovc for purpose of vle.). QTY. PLUMBING PERMIT FEE FLOODZONE APN
LJ L as owner of the property,am exclusively mntrading with Ilcenxd PERMIT ISSUANCE
contractors to c'ommuct the project(Sec.70K Business and Professions Code:
The Contractors License law does net apply to an owner of property who ALTER-DRAIN VENT-WATER(EA)
builds at improve theman, and who contracts for such pZojects with a FEE SUMMARY
myTactor(s)limnsed pursuant to the Contractor's License Law. BACK FLAW PROTECT.DEVICE
LJ 1 am exempt under Sec _, B 4 P C for this reasonOUTSIDE
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
ES
Owner) 1 a Date • r RECEII'N
WOR"ANCOMPENSATION DECLARATION ED(.NRFS PER TRAP SCHOOLTAX Y_ N_
❑1 hereby affirm that T have a certlRcate of consent meet(-Inmre,or a RFLFRrr p
lificate of Workers Compensation Imuranae ma certifhd mpythereo((Sec. GAS EA SYSTEM-1 INCAOUTLETS PARK FTE Y N
3800,lab CJ RECEB'r x
Com p GA
FCS FA.SYSTEM-OVER4(EA)
BUILDING DI VISION FE ES
eytified copy d hereby furnished. GREASE/INDUSTRL WASTE INTFRCFPTOR PLANCHECK FEE
F-1 Certified copy b filed with the city Inspection division. /e/(y
CERTIFICATE OF IXEM PTION FROM WORK ERS' GREASE TRAP PAID bAO / 76-
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 2WF1. Date RCCCI IN
(Thissedlon need net be completed lithe permit inforons hundred dollars
(S100)orless.) WATER HEATER W/VENT/E.ECTR ENERGY FEE Y_ N_
I mrtifythat inthe performincnofthework forwhichthis permit is issued, �l U
1 shall not employ any person N any manner so as to become subject to the WATER SYSTEM/TREATING '—�
Workers Compensation Laws of Callfomia. Date PAID
QZ Applicant NEW RESIDENTIAL PLMB. SQ.FI'. Dafe Remi t71
Z O NOTICE TO APPLICANT:If,after maks ng this Certificate of Exemption,you
should became subject to the Workers'Compensation provision of the Labor TOTAL:
H N Cod,you at forthwith comply wlthsuch provisions mthis pemNtahallbe
j deemed revoked. BUILDING FEE -�
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE r
Il O I hrmbyafRrm that there is a construction lending agency for the perform TOTAL: ELECTRIC FEE
7 Z ance of the work for which this permit b bected(Sec.3097,Civ.C.) PLUMBING FEE
LL O Le.Landera Name TY. MECHANICAL PERMIT FEE
LL F LenI cr'slkddresa Q MECHANICAL FEE a
U correct,
tdgrent complye read in with all city and county
ordinances and
gate
eation
am (
O W Bcoingtobgreeto comply with all cityandcountyacrepnceeand statelawa PERMIT ISSUANCE �oy FEES PAID:
r V) reytingmbupongconsive,crn,and hereby authorize reprexnpurpoa ofthio
Z cityW)to agree
to the,indconify an it property for Inspection purpose. ALTER OR ADD TO MECH. • �0 DatC RCLCIPt4I
— (We)agreeto save IndcnWts andkeepharmless the City of Cupertino AIR HANDLING UNIT TIO 10.ODO CFM)
against BabiBues,pdgmema,costs and expense which may in anywayacaue SUBTOTAL:
against i Cry In con uen I f this permit. CONSTRUCTION TAX
// e��� AIR HANDLING UNIT(OVER 10,0D0CF.M)
Sjv�tll& Applicant/Contractor Date E%HAUB'r HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant store or handle hazardous HEATING UN7T(TO 100,000 BTU) Date ReceI t4
material as defined by the Cupertino Municipal Cod,Chapter 9.1 2,and the
ileallh and Safety Cade Section 2S.532(a)7 HEATING UNIT(OVER 100,000 BM TOTAL:
❑Yen �No
Will the applicanlorfuture building ompant use equipment ordevices VENTILATION FAN(SINGLE RFSID) ISSUANCE.DATE
which emit havardoud air contamdnsnts a defined by the Bay A.Air Pa/yt W
Quality Management rEtMd7 BOILER-COMP(3HPOR 100,000 BTU)
4YNo
hveread the bA.,materials requirements under Chapter 6.95of BOILER-COMP(OVER 100,000BTU) NOV 02 1990
the California health k Safety Code,Sections 2SW5,25533 and 25534. I
understandtl tifthebulldingdoenotarrcntlyhaveatenanLthatitbmy NEW RESIDENTIAL MECH. SQ.IT.
responsibility to notify the ocmparat of the requiremerus which must be met
fd CertiCity of PI�oertina
priors uanm oficst f0c pa
er oravthorived agent Date TOTAL: �� ISSUEDBY:�
OFFICE COPY