19660 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prded Identlflcatlon PFTBMIT NO.
Buirding Add ress: a� ^ O
Zl 05 S 67 1'Q GSC I �M/
weer. , Phone:
/ � -
RFQame. • �,�le3i CITY OF CUPERTINO-BUILDING DIVISION
. con u..N.: APPLICATION I PERMIT 2—«�n
O C BUILDING-UECTRICALPLUMBING-MECHANICAL. CATEGORY CONTROL.M'..
Architect/Engineer, Lic.No:
'; " 1 "" •4t''" '' -1 '
CTRIC PERMIT ti'' 1. ',-BUILDING PERMIT,INFO
ELE - ,.FECI � -
Address: ❑ ❑ ❑
PERAIITISSUANCE
LICENSED Ia CONTRACTOR'S DECLARATION
Ihereby dionmeMfMa l-ice3.fthderir ,.londolCh.I.,9(rommene- APPLIANCFSRFSIDEN'TTAL - JOB UES 1(1PDON
LP
Inense I Section force and
died.
.(the Buslnmeand ProfeselomCode,and my ,
Lt.. lain full force and effect. PANELS - • ,
' Lirensc Clam Lic.x
Date Contractor- UP TO 200 ANTS
ARCHITECT'S DECLARATION 201-1000 AMPS \`
aOpq Iunderstandmyplansshallbeusedmpubllcre.Md , OVER TWO AMPS SQ.FT.FLOOR AREA $/SQ.hT.
Licensed Prdcssl.oal SIGNSELECTRICAL .
a 6�WyY OWNER.BUILDER DECLARATION SPECIALCIRCUIT/M
Ihereby afBrmthat Tam exempt from the Contractor's License Law for the -
qqqq following reason.(Section 70315,Business and Professions Code:An d or
Fo
g rountywhichrequlresapermlttocoretrad,alter,improve,derrolish,ormpalr TID4P.METER DR OL NST.
'� 3 anystrudumpdortolb Wuance,abomqulmstheapplimntforauchpermitto
• 5 file a signed statement that he h licensed pursuant to the provisions of the POWI R DEVICES
�w
Contractors License Law(C
hapter 9(commencing with Section 7000)of Dlvl SWIMMING POOL ELECTRIC
O sson3ofthe Buslnessand ProlemlonsCode)orthathelsemmpttherefmmand VALUATION
' the basis for the alleged exemption. Any violation of Section 7071.5 by any
65
applicant fora permit subjects the applicant to a civil penalty W net mere than OUTLETSSWITCHES
g
five hundred dollars($50M.
❑I,a,owner of the property,y,or my employees with ovagce their doleNEW RESIDENIIALEL _SQ.FT.
IYPH CON5EAOCTION
<
compensation,willdothe work andthe structure isnot intended or offered for
O
sole(Sec.7044,Bsl
unessand Prefesal..Code:The Contractors License law
js$ does not apply to an owner of property who builds or leepmees thereon,and
who doessucb work hlmaelfmth=gh hisown employees,provided that such OCC.GROUP RFS.UNITS
bnprovementsarenot Intended or.ffere!forsale,If,howeveq the building or TOTAL:
Improvement issold whAln.neyeamfcomplctlon,theowner-bu lderwlll have 1`
t e urden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING.PERM IT FEE
own �i' p(pOD ZONE nPN
u S as
.or of the property,am exclusively contracting with licensed pggMlT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code: `
The Contractor's License Law does no apply to an owner of Property who ALTER-DRAIN&VENT-WATPR(EM
heads or Improver thereon,and who contracts for such pknjem with a
c�.tt..[[ador(s)licensed pursuant m the Contrad.e.Lt..Law. SUMMARY.
LII am exempt under Sec. B&P C for this reason BACK FLAW PROTECT.DEVICE
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY -V N
• Date RECEIPT If- -
WORKMAN COMPENSATION DECLARATION
[:,I hereby.(firm that I have a rertlRate of consent to selbiwre,or a FIXTURES PER TRAP SMOOL'TAX Y N
rerti(late ofWorkers'Compensation Insurmce ora rerti(ied ropythere.f(Sec. - RECEIPT M
3800,Ian C,) GAS EA.SYSTEM-I INCA OUTLETS PARK FEE Y— N—
Poliry M - RECEIPT a
Com
any GAS EA.SYSTEM-OVER4 LEA) BUILDING DI VISION IT ES
Certifiedd copy is hereby furnished.
F-1 Certified ropy is filed
with
the city
inspection division. GREASEANDUSTRL WASTE INTERCEPTOR PLANCI'IECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATIONINSURANCE SEWERSANITARYSTORM EA 2(JOri, Date Recei t#
(0).e lodion need not W completed tithe permit is forone hundred dollars
(51I mrin less.) WATER HEATER W/VENT/ELECTR ENERGY.FEE Y N
Irerti(y that In the performance of the work(orwhkhthle permit is ieaued, —
I shall not emplo an person Ina manner so u bee ro 'ect to the Workers Co.
fomla.Dase•j WATER SY5fGM/TREATING
PAID
0 Z Applicant t _�J{ n NEWRESIMNUALPLMIL ' Ff. Date Remi t#
Z O NOTICE Lll'er J'f:If,6Tfr mak his Certificate of Exempt[on,you --c'4
shoald2K bject to the Workem' mpensatlon pmvhdom of the Labor - - TOTAL:
WW Code,you must forthwith comply,with such provisions orthis permit shall be
> deemed revoked: BUILDING FEE
a G CONSTRUCTION LENDING AGENCY SEISMIC PEG
I herebyaffirmfor at there is wichthiaermWctlon samd(Sec. agency 3097,Civ.
the perform TOTAL: lll_L� ELECTRIC FEE
� Z once of lhewmk(orwhkhlhLs permit isLssued(Sec.3097,Civ.C.) - lT '
V O lenders Name - PLUMBING FEE (�
IL F Lender,Address QTY. MkHANICAGPERMiT,• FE6 MECHANICAL PGE'
O W Imrtlfythatl have read thisappllationand statethattheabeechtformation
a Isrorrect.I-greet.complywlth alletyand rountyordinancesand st.mlaws PERMITISSUANCE FEES PAID:
W relating to building construction,and hereby authorize representatives ofthis -
Z dtym enterupon the above-mentlorM property,for Inspection purposes. ALTER OR ADD TO MECH.
— (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
against liabilities,Ndgmxmts,costs and expense.which may In anyway accrue MRHANDLINGUNITED 10,0DO CFM) SUBTOTAL:
agaWts it nroneequen thegrantl2g thb` Jt, MRI-IANDWNG(IMT(OVER 10,000 CFMI CONSTRUCTION TAX
m bf Applicant/Contractor T _DataD ExHni>ST tIooD(w/Duch CONSTRUCTION TAX PAID:
HAZARDOUSM RIALSDISCLOSURE
Will the applicant or fuum building occupantstore or handle hazardous HEATINGUNIT(7010LIl00BTU)
maDate Recef t#
material as defined by the Cupertino Municipal Code,Chapme 9.12,and the
Health and Safety Code Section25532(a)7 I(EATING UNIT(OVER 100,000 HIM TOTAL:
❑ Yes M No
Will the applicant or future building occupant use equipment.,devices- VPNIiLATION FAN(SINGLE RESID) .ISSGGIDATE
which'emll hu>a rdous air mntaMnSn[s as defined bythe Bay Area Al( - �LIANN 2
Qdality Mamgement Dktdd7 BOIhE2-COMP 0HP OR 100,0(10 BTU) I'
4Yes �'7.a IJJV
havemad the haza7ousnuterlalsmyuirmentsunderChapte,6.95.E ROLLER-COMP(OVER 100,000BTU) t
the Gli/ornla Health&Safety Code,Sections 25505,25533 and 25534.I
understand that lithe building does not currently have a tenant,that it is my NEWRESIDENTIALMECH. . SQ.FT. '
responsibility to notify the occupant of the requirements which most be met. Ci1T'r •,p r'P"3TI100
prior to Issuance cis Certificate ofOcapanry. - ^ e�-.
Owner or authorized agent - Date ISSLUE"DIOY�J[J�.�Aa-a�a.n^�•+"'V �t
TOTAL:
OFFICE COPY