20090 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Pro'ed Identification PERMIT NO.
Building Address:wrier. 20090
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CITY OF CUPERTINO�BUJLDING DIVISION T r / /ALU
�- Contnctar's Name: LI a: APPLICATION /,PERMIT `Y7
CATEGORY
1 BUILDINGELECTRICA4PLUMBING-MECI�IAMCAL T (�
T �Iy Y�L G—�q- QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
.- Addrcse� PERhITISSUANCE •00 ❑ 1:1 1:1 1:1LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm that l am licensed under provisions of Chapter9(comrsoc. APPLIANCES-RESIDENTIAL - JOB DESCRIPTION
Ingwith Sociion 7"Bof Division 3 ofthe Buainessand Prefesslom Code,and my (/n /��J,/���
license lelns fora and effect. PANELS /`� /tlb/I 70A
License Gla® Lich
Date Contractor —UP TO 20DAM
ARCHITECT'S DECLARATION 701-1000 AMPS
tic
0 Z I understand my plana.hall be used as public mourds. OVER 1000 AMPS SQ.FT.FLOOR AREA - 5/sCj.FT.
q�w O
Fi U 'Licensed Professional SIGNS ELECTRICAL
<<<ro OWNER-BUILDER DECLARATION I�s
le • i/x�i!
Thereby affimn that lam exemptm
from Coractore Llanse law for the SPECLILCIRCUIT/MLSC
q�y following reason.(Section rm11.5,Business and Pm prove,.Code:Any city it
F F•3 TEMP.METER OR POLE INST.
county which requite..Fermat e,anatruq asth improve,demolish,or mit tr
anystructurc pdortolta Issuance, rcquiresthc applicant forsuch permit
Ufile a signed statement that he b licensed pursuant to the provisions of the TOWER DEVICES '
52OwContractor's License Law(Chapter 9(commencing with Section 7000)of b Divi-
W30 slon 3 of the Business and Professions Code)or that he earn therefrom and - VALUATION
the basis for the alleged exemption. Any violation of Section SWIMMING POOL ELECTRIC 70315 by any OUTLETS-SWITCHES-FIXTURES
applicant fora Fermat subjects the applicant to a civil penalty dna more than
five hundred dollars($500). NEW RESIDENTIAL ELECTR
/,as owner of the ro `"O'FT' STOru S TYPE CONSTRICTION
p perry,or he employees with wages r offered
for C7¢ compensation wBldcss andothe rk.andthes Code; heiii Conct tended orrcense Lw
5�O dale Ince 7014,to alnowandf property,
Code;The or
tiaras Law
$ does not apply to an owner d property who n Imp or improves thereon,and OCC.GROUP RFS.UNITS
who does such work Mrtaelforthrough his ownemployeea,provided that such '
Improvementsarc not intended orolfercd/m sale.ILhowevegthebuildingor TAL: ,b0
Improvement bsold withinoneyearbfcompidlon,theowner-bullelerwlll have '
t rd notproving that he did not build or improve for purpose of ale.). QTY, PLUMBING PE IT I, FEE -
e owner of the property,am exclusively contracting with licensed FLOOD ZONE APN
enact the project(Sec.7014,Businessand Professore Code: PERMIT ISSUANCE
Ise License Law does nae apply to an owner d property who ALTER-DRAIN&VENT-WA IN
OUTSIDE FEES
W s or reproves thereon, and who contracts for such projects with a FEE SUMMARY
actor(.)licensed pumuanf, the Contractor'.License Law. gq�pity pR ECT.DEVIC
I am exempt t oder F B &P C for thb'rcawn
DRAINSFIOO OOF,A D. SANITARY Y_ N_
f Owner Date RECEITTN
IWOKAMAYCOMPENSATIONDECILARATION H%TIJRFS I'ER SCHOOLTAX Y_ N_
❑1 hereby affirm t t I have a artiflcate of consent to alfArsurc or RECEIPT N
certificate ofWarkere ampereation Insurance m a'oenifled copy therenf(Sce. GAS E.A. OUTLETS BARK FEE Y_ N
♦- 3800,Lab C.) RjGE=7
—" GASEA.SY V 4(FM BUILD INGDIVISIDNFLLS
Cocam any
CenlRed copy V hereby(urNshed. GREASE/INDUSIR WASTE I R LANCHECIC FEG
❑Certified copy b filed'With the city inspection division.
CERTIFICATE OF EXE?e!FTION FROM WOR K ERS' GREASE TRAP PAIDty—-t—% ' _ �-C T�O sl
COMPENSATION INSURANCE SEER-sANrTARY- RM EAS Date - Remi t# 7o.7O
' Qhlssertion need not W completed if the permit is forone IN
hundreddolLus
I^ ($100)or led,.) - WATER HEATER W/VFNT/nl)CTR ENERGY FEE. Y_ N_
I certify that In the parfor anaofthe work for which this permit is lased,
1 shall not employ any person In any runner no an to become subject to the WATER SYSTEM/TREATING
Workeri Compensation Laws of California. Date PAID' 1J7w ['�1d
`O Z Applicant NEW RESIDENTIAL PLM B. SQ.FT. Date Renal t# J Kco
Z O NOTICE TO APPLICANT:If,after making they Certificate of Exemption,you
should become subject to the Workers''Compenaation proal ions of the Labor TOTAL:
H W" Code,you must forthwith comply wltAsuch provisions orthispermitshall ba, IDI -Ddt
CC
jdeemed mvaked.
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE _
CL Iherebyaffirm that thea b a conatmction lending agency for the perfortry TOTAL: ELECTRIC FEE- s�0
7 Z ance of the work
for which this permit V Issued(See3097,Civ.C.)
O O tender's Name PLUMBING FEE
LL. h Leader.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FGE
O W Ianlfythat l have read thbapplicatlonand A.tethauheabove Information
N correct.l agree to Comply with all city and countyordinances and nate laws PERMIT ISSUANCE FEES PAID:
} N relating to building construction,and hereby authorim representatives of this . .
I— city to enter upon the abovcmentloned property for inspection purpose.. ALTORADDTOMECH.
Z (We)agree to save,indemnity an d keep hameless the City of Cupertino Date Receipt#
U against liabilities,judgments,costs and expenses which may in anywayaceme AIRHANDUNGUNIT(1010,000CF1,I) SUBTOTAL:
against said City in consequenre of the granting of this permit. FIR HANDU NG UNIT(OVER 10,000 CFM) CONSTRUCTION TAX '
( Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicant or future building occupant store or handle haardous HEATING UNIT(TO 100,000 BTU)
materials.dfned by the Cupertino Municipal Code,Chapter 9.17,and the _ Date Recel t#
Health and Safcty Code Sectlon75537(a)7 - HEATING UNIT(OVER 100,000 BTU) AfdnL:
❑Yes MN.
Will the applicarilfutua building occupant use equipment or devices VGTDLATION FAN(SINGLE RESID) ISSUANCE DATE
hicheMt havardom air contaminanu as deflmd by the Bay Arca Air•
Quality Management District? BOILER-COMP pFI'pR 100,0W BTU) 1A
AY U1 IySU
4Yea M1�I No
haveread the haea-nTous materials requimmentsunder Chat pter6.95of BOILER-COMP(OVER IM,000BTU)
/ theCallfomiaHealth&Safety Code,Sectiona75505,25S33and 755M.1 City of COnp.(tjno
'd4. uwnderstand that if the building does not currently haveatemsnt,thatblsmy NEW RESIDENTIAL MECH. 5Q.FT.
_ resporalbil(tytonct(fyt oceupantoftherequlrcmentswhichmustbemet
prior to Issuance of ficateof Occv an ///�fff
owners e Iss Do
l/7�GG��
TOTAL: /
OFFICE COPY \