20208 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address:
ME`fEoR ��• _ 20208
sAPPUfnK7r5K7lJ9PTTrA77=
JOHN 'FL00Q �3$_ ane. Q CITY OF CUPERTINO-BUILDING DIVISION
c'ampr`aaar•af�lame: LIc.Na V APPLICATION it PERMIT �/ V
GKTf �Va GooPER C.LXfAT_ Z4�4 BUILDINGFI,ECTRlCA4PLUMBINC-MECHANICAL CATEGORY CONTROLX
Raw Architect/Engineer. Ge Na:
QTY ELECTRIC PERMIT FEE BUI ING PERMIT INFO
Address: PERbITISSUANCE ❑ ❑ ❑
LICENSED CONTRunder provisions
IhthSyion7Othat lam)(AsionudueBuM waAdPffhmsr9de,and nc- MPLIANCESRESIDENML JOB DESCRIIVITON
Ingwlth5ettion7(100)of Dlvislon3otthegusinevand Prolesaona Code,and my
licen¢I,I full ancielfect. 6 PANELS
License _� LICX OZ S�I
Date_ C�Cont�� 201-1000 AMPB
ARC Inc EC CATION OVER IOOO AMPS SQ.F[.FLOOR AREA 4/SQ.FT.
as7070 1 understand my plans shall Mused as public rewrda.
Licensed Professional SIGNSELECTRICAL
6 Q m OWNER-BUILDER DECLARATION
F, a. I herebyaffiren that lam exempt from the Contrac4ora License law for the SI'ECIALCRCUIT/MISC
O_- following remon.(Betion 7(01.5,Business and Professions Code:Any city or TEMP MEfIR OR POLE INST.
countywhic requlrcaaper ttocomtmMalteglmprove,demolbh,orrepair
F s."'li anystm=mpriortoitsbauance,aaorequlrestheappbmntforwchper tto POWER DEVICES
Vfile a signed statement that he t licensed pursuant to the provisions of the
Contractor's License Law(Chaer 9(conrencin ith Section 7000)of Owl.
II..30rn sion3 ofthe Business and ProtesmtonsCom)orthat he is exempt therefromand SWIMMING POOL ELECTRIC 4L TION
Et S2 the basis for the alleged exemption. My violation of Section 7MI5 by any OUTLETS-SWITCHES-FIXTURES
!y<r
applicant for a permit subjects the applicant to a civil penalty of Ra rrorethan
five hundred dollars($500). 1 NEW RESIDENTIAL ELECTR .4T.
.. ❑1,as owner of 1M property, —ems S RIES TYPE CONSTRUCTION
p perry,or nd he employee with wages as 1MR sok
is
d for
�7<
compensation Busiocas andwill dothe K fesslo st ode:The Cont endedactor or offteres,Law
$�O vie(Sec.7034,Busk�ess and IProfesslons Code:The Contactote LI¢me Law
F:$g does not apply to an owner of property who Wilda or Improve thereon,and OCC.GROUP RES.UNITS
who dorsauch work himself or through his own employees,provided that such
improvement arc not Intended oroffered forsale.If•howwer,thebullding or TOTAL:
Improvement issold wlthinomyearotcompl0ioRtheowner-builderwill have
th,L4urden of proving that he did not build orimprove for purpose o(sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
4 as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec 7044,Business and Professions Code:
The Contractor's License Law does eat apply to an owner of property who ALTER-DRAIN&MEM-WAIIIt(EM)Wilde or improves thereon,and who contract, for such pAojecis with a
roFEE SUMMARY
yyTTaetor(q licensed pursuant to the Contractor's Ll¢nse Law. BACK FLOW PROTECT.DEVICE
Lj I am exempt under Sec. B k P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEIVTN
WORKMAN COMPENSATION DECLARATION FATURES PER TRAP SCI TOOL TAX Y_ N_
❑f hereby orf that I have o imus to of consent to opythemc ora RECEIVE X
certlflrate of Workeri Compematlonlmurance ora cercified ropy thereo((See. CAS EA.SYSTEM-1 INCA OU1TLET5 PARK FES Y N
3800,lab C.) RECEIVE X
Policy N GAS F.A.SYSTEM-OVER 4(EAI BUILDING DIVISION FEES
Com a
nrcl(Idropyishereby fumishd. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified ropy is filed with the city iespeaion division.
CERTIHCATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEINER-SANITARY-STORM EA.2004T. Date Renal t#
(This section nand not be completed if ted permit Is foram hundred dollars
($1M)orless.) WATER HEATER W/VENT/E.ECTR ENERGYFEE Y_ N_
I¢rti(y that Nthe perfommn¢af thew farwhlcht pennl aWued,
I shall not cm I person In any ma er,o a to to the WATER SYSTEM/.TREATING
Work Ion Laws of I( .DateLq_ PAID
Z Z NO 'PLICA .IL aker making this Certifi to o(Exe piston,you NEIN RESIDENTIAL PLMB. SQFT. Date Revel t#
sh me aubjeetI he Worken'Compensatm rovislamaftheoWr TOTAL:
F W Code,youmustforchwilhromplywithsuch provisi orthispernitshallbe
CC j deemed revoked. BUILDING FE
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE
IL Iherebyaffirmthat there t a construction lendingxgency forthe perform TOTAL: ELECTRIC FEE
7 Z aA..fthe workforwhichthis permit is bauN(Sec.3097,CIv.C.) PLUMBING FEE
V O Lender's Name
LL f 1<ndce,Addreas QTY. MECHANICAL PERMIT FEB MECHANICAL FEE
OW 1arrilythatI have read this application and statethatthe above information
a is morct.l agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES A S
} relating tobullding construction,and hereby authorize representative of this .l
N city m enter upon the above-rrentiond property for impecton purposes. ALTM-ORADDTOMECH.
_ Z ate Receipt
(We)agree to save,Indemnify an d keep harMess the City Cupertino
O against llabllitle,7adgmeme,com
st and expenses which ay In anyy wayaccrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said city In con equea¢of the granting of this permit CONSTRUCTION TAX
AIR HANDLING UNIT(OVER1B,000cFM)
Da
Sigmtureof Applicant/Contractor te EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a pplimntorfown,be llding occupant store or handle hazardous HEATING UNIT(TO l 00,WO BTU) Date Remi t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
I l alth and Safety Cdr Section 25532(a)i HEATING UNIT(OVER 1W M BTU) TOTAL:
❑ Yea M No
Willtheappllcant or future building occupantuse equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hamrdowair co uunma.tas defined by the Bay Area Air
Oo lity Management District? BOILER-COMP OHPOR IMOM BTU)
4Yea No PAID
havereadthe h z�ouamaterial,requirementundo,Chapter 6.95of BOILER-COMP(OVER100,000 BTU)
the life mla Heath k Saf BotCode,Sect Ions 25505,25533 and 25534. I APR
R p Rb J
undcrstandthatifthe Wlldin doe,ncurrentl haveatenanLtotittmy MSQ-FF.NEWRESIDEIALMECH. SQ. . r9yv
responsibility to notify the occupant of the requirements which most be met
prior to issuance of a Certificate of Occupancy.
ftPiti !
Owner or authorized agent DateISSUED BY
TOTAL:
OFFICE COPY