20695 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Prajed Identifiodim PERMIT NO.
Badding Address` 20695
10 Q- r c-c-L-
w 1% one: A A A A
CITY OF CUPERTINO-BUILDING DIVISION ter' O
.o tr 'sName: Llc.No: �-{- APPLICATION / PERMIT
Bl.-fLU1NGEELECTRICALML BINGMECH N7CAL CATEGORY CONTROL
Architen/Eieginmr. Lie.No:
QTY.'' ELECTRIC PERMIT s FEE BUILDING PERMIT INFO '
Address: PFRMITISSUANCE ❑ [:1 [:]LICENSED CONTRACTOR'S DECLARATION
I hereby a(linn thatlam Bcemed underprovisione of Chap[er9(mmmenc APPLIANCESRESIDENTIAL JOB DESCRIPTION
ingwitteSecdon70007of Diveon3ofthe Buaioessand Pria—unsCode,and my PANELS
limnse o In fuBvforc�and effect. —...a / 1
Limn fse.Claa /(1 Lich LFO �f
Date (_ra I ContractorARCHITECT /'1� /
AACHITECPS DELLA TION J OVER
AMPS
0 Z I understand my pion.shall be used cue public records. OVER 1000 AMPS SQ.Ff.FLOOR AREA S/SQ.ET.
900
a�� Licensed Profesaion.l SIGNSELECTRICAL
H<d. OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MIX
L., 3 I hembyaffirm thatIam exempt fromthe Contractor's License Law for the
fu0owteg mason.(Section 7031.5,Business and Profession.Code:Any city or TEM p,MEfE20R POLE U
y,a muntywhlchrequU apemutmmmtrua,alter,Lmprove,d,mn h,ormpnr
anystmctumpriortotOWuamc aLsorequr NeappBantforsuchper tto POWER DEVICES
ufile a signed statement that he In licensed pursuant to the provbtom of the
u,
Contractor's License Law(Chapter9(commencing with Section 7000)of Divt- SWAIMING LELECTRIC VALUATION
SLLOS slon3o(the Busineseand Profcsslon.Code)orthrt he iceumpttherc(romand
Q the basis for the alleged exempt on. Any violation of Section 70312 by any OUTLETS TC FIXTUR
applicant for.pemdt subj the applicant ton civil pe�ltydna mom bun
.. $ five hundred dollars(S500). NEW IDENTIA EC FT. STORIES TYPE CONSTRUCTION
.- 4,as owner of the property,or my employees with wages as their In
Cc< mmpensatlon,wBl do the work,and the swcture is not Intended or offered for
F O sale 5m.7044,Business and Profession.Cade:The Comactoes Umn.e law
$ dues not a pply to an owner of prop"who bu ilds or improves therton,and OCC.GROUP RES UNITS
$^ whodoessuchwork himselforthruugh hisownemployees,provided thatsuch
Improvements are not Intended oroffered for sale.If,however,thebulidingor TOTAL:
Improvement issold withinoneyearofcompleiamtheownerbudderwdlluve -
OIL, jni
en of proving that he did not build or Improve for purpose ofsale.). QTY. - PLUMBING PERMIT.` .'FEE,`' ELOODTDNE APN
u 4 as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to mmvuct the project(Sec.7044,Business and Profevbm Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN Na VFM-WATER(EA)
builds or Improves thereon,and who mntacte for suntwith a - `
m,tBTanor(sBBeensed pursuant to the Contractors License Law.
BACK FLOW PROTECT.DEVICE -•� FEE SUMMARY
Lec I1 am exempt under SB h P C for this mason N
Dae DRAINS FLOOR SANITARY Y ROOF,AREA,GOND. REGI
Is
WORKMAN COMPENSATION DECLARATION ARES PER TRAP SCHOOL TAX Y_ N_
II hereby affirm that I have a melfise of consent to sect-buurc,or RECEIPT N
ice fiaateo(Worke Compen.tionln.uranmwacenifl mpythereaf Gee. GAS E.A.SYSTEM-1 ING4 OUTLETS PARKFEE Y N
3800,lab C.)//��
Po11ryM_L,( Q 'Z ^('— GAS BUILDING
EA.SYSTEM-OVER4ITA) Tp
r Com an 1j DI VISION FEES
�cedifiedcepyb cre fumished. PLANCHECK FEE
rG7 Certified copy b(Bed with the city Inspection division. GREASE/BJDL1SfRL WASIEi EPTOR
'M CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID
COMPENSATION INSURANCESEWER-SANITARY- MEA 7110ET. Date Reeel t#
(this section need not be,completed u the permit Is for use
hundmddollan ENERGY FEE Y N
(91000orleso.) WATER IffATFA VFM/ELECTR —
I wrtify that N the performance of the work far which this permit is Issued,
I shall not employ any person In any manner ad as to become subject to the WATER SY /TRFATI[.'G
worker;campenaanor law.of aluamm. PAI D
O Date Z APPBant NEW RFS[ AL PLMB. SQ.FT. Dale Recel t#
Z O NOTICETO APPLICANT:Ifft.,ma king thio Certificate of Exemption,you
should become subject to Me Workers'Compensation provisions of the Labor TOTAL:
fA Code,you must forthwith comply with such provolone orchis permit shall be BUILDING FEE
deemmed 1eVOked' SEISMIC FEE
LU CONSTRUCTION LENDING AGENCY
CL Iherebyaffirenthe there is a construction leMingagency forthe performnTOTAL: ELECTRIC FEE
':D Z ance of the work for which this permit o Issued(Sec.3097,Cie.C.) PLUMBING FEE
O I<nderb Name MECHANICAL PERMIT FEE:.
F Lenders Address �Y' • MECHANICAL FEE
1 U I wnffythat l have mad this appliationand statethat the aboveln(crenatter '
O W lacorrcct.i agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. 1 reining to building construction,and hereby authorize repreaentativea oftho
N city to enter upon the above-mentioned property for mapecttun purposes. ALTER OR ADD TO MECH.
? (We)agree to save,indemnity an d keep hare-Jess the City of Cu pemtino Date Recef t#
V against BabiBties,judgments,costs and expen es which may N any wayacaue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
againa1t id Cityl consequenceofthe granting ofthl 't.
�/t) U6d, Y1� AIRIiANDLIh'GUNTF(OVEJt10,000CEM) CONSTRUCTION TAX
Sign. o App ant/Contmoor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theappliant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCCCI t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the aty�
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,ODO BTU) TOTAL: U✓
M Yes ri No
Wiilthe applicant or lutum building occv partuse equipment.,devices VENTILATION PAN 6I\CLE RFSIDI ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management Dlstrid7 / BOILER-COMP OFII'OR 100,01s)OTUI it e1
4Yca I❑�I No BOILER-COMP(DYER 100,(100 BTU)
haereadthelaza dosesmtchabmquime ntsunderChapter6.95a(
the California Health k Safety Code,Sections 75505,75533 and 25534. I
understand that lithe building does not currently have a tenant,that it o my NEW RESIDENTIAL METH. SQ.IT.
responsibility to really the occupant of the requbemennwhich must be met
Prior to issuance of.Certificate of Ocxupanry.
Owneroceuthonmd agent Date TOTAL: Cl(, ISSUEUIV: _' l` tn_ l
OFFICE COPY