21270 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Build in Pru'eni Identification PERMIT NO
.
aaf..�sst
Building Address: ZO QZO G e AW /1 / O
capek.'tiNct CA • YScI 2 f [,1
w. one: APPLICA PON SUBMI I I AL UA
3-111 -( /(U6-0'760 CITY OF CUPERTIN6BUILDING DIVISION
Contractor's Name- Lc.N0: APPLICATION if PERMIT t L
12OGS EleckRC G'IO y*0 r7G RUILDINGE(.ECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL
Archurct/Engineee Lk No:
Q .•ELECTRIC PERMIT, �. . FEE.,.• - BUILDING PERMIT INFO
Address PERMBTISSUANCE Cn ❑ C El ElLICF.NS ED CONTRACTOR'S DECLARATION J�1
I hereby dfirmthat lam licenced under provisions o(Cha pier 9(comment, APPf1ANCESREADENML JOB DPSCRD'HON
ingwlth5 dion7000)of Divi.ion3ofthe Butli.andProfmionsC„ode,and my PANGS
license a Is in full forand died.
License Clan a-!D Lich 00'�6
Data 1 b I to f q o Contact.nffi�l roc.
ARCHITECPS DECLARATION 201-I000AMPS
j p Z I understand my plans idoll c itacd as public records. OVER IOW AMPS SQ.FT.FLOOR AREA $/SQ.FT.
CO
Licensed Professional SIGNSELECTRICAL
L OWNER-BUILDER DECLARATION
^�C' Ihercby. irmthatlamevemptfromthe Untnn..i License law for the SI'ECIALCI(CUfT/M1SC
following reason.(Section70)15,Butlnessand Professions Ude:Any city or TEMP MEIFR OR POLE INV(.
Q countywhich Tnquiresa permit mmrutruct,alter,improve,demolbh,orrepair
anysaucture prior torts lasuance,alwrequiresthe appliantfa.uch permit to
1v V file a signed statement that M Is licensed pursuant to the provisions of the POWER DEVICES )
70, Untncore Liceruelaw(Chapter9(mmmendngwith Se ion7OOD)of Divi- SWIMMING P00=CW) W VALUATION
=0�^ sion3ofthe Businmand Profmioro Code)orthathebe mptthenfmmand
the basis for the alleged exemption. Any violation of Section 70315 by any OUTLETSSWITCHFSFI ES
applicant for a permit subjects the applicantto a civil penalty of not more than
ipz five hundred dollars($500). NEW REBID AL STORIES TYPE CONSTRUCTION
5 ❑1,as
.,of the property,or my employee with wages as their In
_2� mmpensaHon,wllldothe work+ndtheatrocture Vnotimended or olfeml for 1
GG- O sale(Ss..7014,BasWss and Pretensions Code:The Contractors Wceme law
ai,sR does nm apply to an owner of property who build.or improves thermn,and OCC.GROIIP RES.UNITS
who doe such work himself orthrough his own employees,provided that such LL
4nproverrcntsamemiatended..offered for ale.It however,the buildingor f TOTAL: f�
improvementbsoiwithinhe did odbufl pldtorvthee for pupongod Bl have -
tF.jurdeno(proving thrtMdid nof build..improve(or purpose oleate.). QTY. .:; '.PLUMBING PERMIT ' ,'FEE:` FLOOD ZONE APN
L—I L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to constrict the projed(Sec.7016,Business and Professions Code:
TM Contractor's Lim.Law does not apply to+n owner of property who ALTER.DRAIN&VENT-WATER(EA) _
build. .r Improve thereon,and who contacts for such pi press with is .'FEE SUMMARY-'
`
OqN(+dorte)Banseec d pursuant to the Contnctor+License Law. BACK FLOW PROTFGI.DEVICE -rt- -
ETI +m exempt under SB&P C for this reason
OUTSIDE FEES
DRAINS FLOOR,ROOF,AREA,GOND. SANITARY Y N_
• Owner Date RECEIPT a
WORKMAN COMPENSATION DECLARATION FO(T1IRFS PER TRAP SCHOOL TAX Y_ N
❑1 hereby.(Tisco that I have a artifiale of consent to"If-insure,ora RECEIPT N
arti0ateofWorkers'Compensati.almomance or a certified copy themof(Sec.
3800,Lab CJ GAS EA.SYSTEM-1 A'G40VILEIS PARK FEE Y_ N_
RFGEI7 M
Policy N GAS FA.SYSIEM-OVER 4(EA) BUILDING DIVISION FEES
Uffany
Cemfiea copy a hereby famished. GREASE/INDUSIRL WASTE Dn ERCEPTOR PLANCHECKFEE
❑Candied copy at filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.2WET. Date Remi t#
(Thiasection need not be completed tithe permit bfor one hundred dollars
(SIM.Hos.) , WATER HEATER w/VFM/F1.ECTR ENERGYFEE Y_ N_
1 certify that in the perfapermitunceotthe work forwhich this permit is issued,
I shall not employ any person In any manner ao as to become sub' to the WATER SYSTEM/TREATING
orkeri,Cononsation,Law aof Cal/fo�mI..Date !O O O PAID
Z Applicant /! kew"t— COra'�6 NEW RESIDENTIAL PLMB. SQFI. Date Recei t#
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
- � should become subject to the Workers'Compensation provisions.(the Labor TOTAL:
N Code,you must forthwith comply with such provisions orthb permit shall be 13TJILDING FE
deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction minding agency for the perform TOTAL: ELECTRICFEE
) Z anceof the work for which this permit fs Issued(Sec.3097,Civ.C.) PLUMBING FEE
OLender'sNara MECHANICAL PERMIT FEE
f Leender's Address MECHANICAL FEE
uxt
W Irract.I agree tcmply with
allcityndcuntyordinances and gate
FEESPAID:
S is mmnt Gilding comply with andhereb countyordinances
representatives
and nsafthis PERMIT ISSUANCE
W
relating wbupon t construction,and hereby authorizerepresnpurposa(thk
Z
city Wenter
eetoled,indemifyawd property for Wpactl it purposes. ALTER OR ADD TO MECH. Date Receipt#
_ (We)agree to aa,indemnify an d keep harmim the In
of ywayac ino
agaWtlhbilfJes,Ndgmenn,mxsand expenses which may In anywayaccrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against ova city in consequenm of granting of this permit. CONSTRUCTION TAX
/D/
/� I.�,f' Cra• T+' to/ 40 A1RH"`.rDUNGDNTTrovERIo,DDOCFMf)
Signature of Applicant/Contractor —$in EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA7 RDOUS MATERIALS DI SCLOSU RE
Will the a ppliant or now re building part store or ha ndlc h.,dous HEATING UNIT(TO 100,000 BTU) Date Reeei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Salary Code�SectJ^^7553NO? HLATING UNIT(OVER I W,000 BTU) TOTAL:
❑Ye L�Fo
W0lthe applicant or furore building occupant use equipment or or,,. VENTILATIONPAN(SINGLE READ) ISSLlAN(�FIDATE
which emit havrdous air contaminants as defined by the Bay Area Air e���/
• Quality Management Dist' BOILER.COMP DHP OR IW,000 BTU) t
4 Yes L) 1990
Tuve read the hon ons matcriab requirements under Chapter 6.95 of BOILER-COMP(OVER 1W,f100 BN) G[; I Z
the California Health&Salary Code,Sections 25505,5533 and 75511.1
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. ,,{ ,,
Tesponsibility,to notify the occupant of the requirements which most be motCity V:Cvr� t 100
prior to issuance of a Urti(iate fOmpancy.
Owner or authorized agenta— t3( e - ISSUEDBY:
TOTAL:
OFFICE COPY