22011 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Bulldin Address: 4, /1 f1 0 a�
ro y"Oo1� C GG I
r. ame: c A
G°� aqp fg L4 CITY OFCUPERTINO-BUILDING DIVISION `
ar� LIc.No: APPLICATION I PERMIT '3�l
. — 57n<, BUILDINGELECTRICA[.PLUMBING-MECHANICAL CATEGORY CONTROL#
Arc ed/Engineer. Lk.N.
QTY ELECTRIC PERMIT FE,OEE..,, BUILDING PERMIT INFO
Address; PFRhgi(SSUANCE lam/ _—BLU(J ELELI PLUMB MELEE
❑ (tea ❑ ❑
LICENSED CONTRunder provisions
- 1�
I hereby Irmthat lam EcensecueBuMm land Pm Cssims9de,and c AIPPHANCES]tESIDENTGlirgJOB DESCRIPTION
tare .h.full 7000).rd effect.
lon3otthe Busimssand Prolceelona Code,and my �
license Cie tali farce and c.# PANELS
LlcenaC Class LIc.M '
Date Coctrattor —UP TO 200AM5
ARCHITECTS DECLARATION 701-1000 AMPS
ox O I understand my plans @hall be used as public records OVER 1000 AMPS _ ^ OSQ F7�FLQOR�iG D �S`Q,Fr.
Licensed Professbml SIGNSELECTRICAL Oh\VI NEE E N
<<<kCu. OWNER-BUILDER DECLARATION O M P R
a SPECIALCItCUfT/MISC
z p,,,l Thereby a(Orrn that the LARAR rb Limnx law for the
following reason.(Section 70i15,Bush.and Professions Code:Any city or TEM /a�� „n
FF' munywhkhrequlresape ttommu malter,improv.,de.1ih,arrepalr IP'METERORIPOLE[NST. `�V `�/ �.G�e
Q45aQ anystro.men prlarte its Issuance,also requirestheapp0ont for such permit to TE T/
S 0 U file a signed M.ement that he is Brensed pursuant to the pmvNlam of the (OWER DEVICES
G61 Contract.?.Lkeme Law(Cha er9(mmmencin with Section 7D00)o(Dlv1-
SWIMMING POOL ELECTRIC slon3 ofthe Bu.bessand Prvfemiom Code)ortht he is exempt therefrocrand VALUATION
< the basis for the alleged exemption. Any violation of Section 7!2)1 S by any OUTLETSSWIPCHFSFIXTURPS
O
applicant fora permit subjects the applicant to a civil penalty of not more than
flu ffundred dollam($500). NEW RESIDENTIAL ELECTR SQFI'. c STORIES TYPE CONSTRUCTION
�n I,a@ owner of the property,or my employees WE wages as their sok
compensation,will do the worl:and the structure Is not Intended or offered for
qsale(Sec.7064,Business and Professions Code:The Contradots Liu.law
does not apply to an owner of property who Wilds or Improves thereon,and OCC,GROUP RFS.UNITS
who does such work himself or through his own employees,provided that such
Improvements arc not Intended oraffered for We.If,however,thebuliding or TOTAL:2D,C6
improvement bold wllhlnoneys, ..fe mpletlon,thn owner-bullderwlll have
OiLti+eden of proving that he did not build or Improve for purpose of We,). QTY, PLUMBING PERMIT FEE
LJ L as owner of the property,am exclusively=trading with licensed FLOOD ZDIdE APN
ro
contractors to construct the pmje (Sec.70K Budge and Professions Code: PERMIT ISSUANCE
The Cantradoes Licrow Law does not appy to an owner of property who
builds ALTER-DRAIN&VEM-WATER(EA)
or Improves thereon,and who contract. for such p( em ojwith
coogd
s)licensed pursuant to the Coetvor's License Law. FEE SUMMARY
LJ Idam exempt under Sec. B k P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
• Owner Date ftFLEIeF1
WORKMAN COMPENSATION DECLARATION FDCUR6S PER TRAP SCHOOL TAX Y_ N_
❑e hereby sfllrm that I have a mnjfll.mote of consent m se141..ure,(S a
certificate o!Worken'Compevatlon Ivuranm m a artifled copy thereo((Sec. RECEIPT
N#
3800,Lab C.) GAS EA.SYSTEM-1 INC.4OUTLETS PARK FEE Y_ N
Policy 0 RECEIPT
Com GAS-EA.SYSTEM-OVER 4(EA)
any BUILDING DI VISION FE ES
Certified copy is hereby furnished.
F1 Certified copy la filed withh the city
Inspection division. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
ity
CERTIFICATE OF EXEM PFION FROM WORK ERS' GREASE TRAP PAID
UR
COMPENSATION INSURANCE
Qhlaeection need CnotO be completed[(the SURA la loronc hundred dollars SEWER-SANITARY-STORM EA.200171'. Date Remi t#
(S1 I ordify that
WATER HEATER W/VENT/ELDCTR ENERGY FEE Y N
Ittrtity that lathe performance ofthework(orwhkhthls permit la issued, —
I shall not employ any person In any manner an a to become subject to the WATER SYSTIM/TREATING
Workers'Compensation Laws m Call(omla.Date PAID
-
zZ NOTIAppliCE B y NEW RESIDENTIAL PLMB. SQ.Fr. Date ReCel t#
Z O NOTICE TO APPLICANT-.If,eller makin this Certificate of&em Ion,you
should become sub),ct to the Workers'Comperuat ion provisions o the Labor TOTAL'
P
N Code,you at forthwith comply wlth.uch provisions or this parrrdt shall be
W > deemed revoked. BUILDING
a E CONSTRUCTION LENDING AGENCY SEISMIC FEE
Ihereby eork that thereiam®wctlonkndingagnncy(orthe perform ELECTRIC FEE
D Z once of the work far which this permit hhsued(Sec,3W7,Civ.CJ TOTAL:
V O IRnder'.Name PLUMBING FEE
LLE- Lend.e.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
I mdlfythat I have readthisappllcadonand statethattheabovelnformatlan
O W
IL Iscorrect.I agree to comply with all ciyand county ordinances and date laws PERMIT ISSUANCE FEES PAID:
>_ reladng to building mmnv
truction,andhereby..flumlec rep .nlative.ofthla
N
U) city to enter upon the above,mentioned property(or lmpecii.n purrppo�eeeee. ALTER OR ADD TO MECH. Date RCCCI t#
— (We)agree to save,Indemnify an d keep harmless the City of Caped Ina
against liabilities,Judgment.,costs a cad9 expense.which may lnany wayaocme AIR HANDLING UNIT(TO 10,000 CFM) tSUBTOTAL:
again(laid In conscgpenreot gnnting of this permit.�
AIft!-iANDLING UNIT(OVER IO,DIOCITt) CONSTRUCTION TAX
gmtur ( pPUn.t/Contractor Da EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the apphant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
ctcrhl as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date RCCCI t#
f kalth and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTLO TOTAL:
RYes No
ill the applicant or tum building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit ha.M..I air contaminants as defined by the Bay Area Air My'A
Quality Management District BOILS&COMP OHIPOR 100,000 BTU) i�-W
4 Yea N No
havemadthchua ou@ma terialsrequimmant@underChapter6.95of BOILER-COMP(OVER 100,000 BTU) r1P� n (111191
the California Health k Safety Code,Sections 25505,25533 and 25534.1 09
understand that if the building does nm currently have a tenant,that it is my NEW RESIDENTIAL MECH, SQ.rr
responsibility to notify the occupant of the requimmenm which mus(be ret /�-sp
Prior to lsvua nee of.Cedlfieate of Occupancy. Alga wS Y4spes" I!P
Owner or auth.rlud agem Date ISSUED BY�M+I IN�SYIUS+ ��..
TOTAL:
OFFICE COPY