21728 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pru'ect Identification 1 v— 'L PERMITNO.
Building Addttga: 1..�
--I 3 h Ccs-lc, Cmc t 21728
/a ante: _ ante: A A A
(�2E O 06, CITY OF CUPERTIN4BUILDING DIVISION
. Contrertar.w� L/ ur.Na: J APPLICATION I PERMIT , '` —�
-''7`.300 / BUILDING-ELECTRICALHUMBING-MECHAMCAL CATEGORY CONTROL N
Architect/Elr. Lie.No
5�7v/LIT✓ Gf/60vr
ELECTRIC PERMTT FEE BUILDING PERMIT INFO
11
QTY
Address PERMITISSUANCE NIS
W
LICENSED CONTRACTOR'S DECLARATION [}J
Ihercby a!(Irm shat[ant licensed underprovtalpns of Chapter9(mmrnmc APPLIANCFSRESIDENfIAL JOB DESCRITION
IngwithSMion70D0)o(MA.i..3ofthe Buri a andPmfesaton.Caee,andmy
Ll�nseGass 11 fo�gnd IT jy 3 Ce� rj PANELS
Date Contractor / .Sr
ARCHITECPSDECLARATION 201r1000AMPS
o`!.O I understand my plaroahall be used as public record.. OVER 10DO AMPS SQ.FT.FLOOR AREA f/SQ.FT.
E Licensed Pr fcssiarul - SIGNS ELECTRICAL 7
OWNER-BUILDER DECLARATION SPECIALCIiCLIT/MI9C ?
i.., IherebyafOrenthat iame.empt fromthe Contracun.License Lawforthe
7 Q following reason.(Section 7031.5,Business and Profession Code:Any city or
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county rcqulresapermitto construct, demolish,orrtpalr TEMPMETER OR POLE INST .S O�
anynmmmpriortoibl ance,alwrequiratheapplicantforsuchpermitto POWER DEVICES
r. file a sig statement that he is licensed pursuant to the provisions of the
aG Contractor;License Law(Chapter9(scommucing with Section 7000)of Dlvl- SWIMMING POOL ELECTRIC
O ai.n3csfibe Businessand Prvfmbro Ccda)orthat hebmm
etherefrod VALUATION
tr
the basis for the alleged exemption. Any violation of Sections man7031.5 by any 7
applicant for a permit subjects the applicant to a civm
civil penalty of not ore than OUILETSSWI'ICHSHXTUIthS O 5— O G'�
live hundred dollars(SS00). NEWRESIDENTIALELECTR SQFI'.
SIOIt1E5 VTYPE CONSTRUCTION1,as owner of the property,or my employees with wages as their sole
cumpensation,willciolhe work and thestructure is not Intended or offered for
Fp sale(Sec.7W4,Bu,i .and Prof.i..Code:The Contractors Liae Taw
does not apply to an owner of property who build.or Improve thereon,and 7�
a- whodoessuchworkhlmselforthrough hisown employees,provided that such OCC.GROUPRIS.UNITS
improv<trcnb are rot Intended proffered fm isle.Ir,howevcq thebulidingor TOTAL:
improvement ts"d withinami earofcompletlon,the owner-builderwill have
to ram of proving that he did net wild or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE '
L..owner of the property, HOOD IDNE APN
p Forty,am exclusively contracting with sCode PERMIT ISSUANCE
contractorsto mmtmctthe project(See 7044,Businessand of pro oro Code:
The Contractor'.License Lw does net apply to an owner l property who ALTER-DRAIN VENT-WATER(EA)
Wilds t improve.thereon,and who contracts for such ptojem with.
co}Ltt.TTa 'orfs)Ocensed pursuant to the Gmtnctore Lken:Law. FEE SUMMARY
L-,J I am exempt under Sec. B 4 P C for this re BACK FLOW PROTECT.DEVICE
awnQUTq1DF FEES
Owner Date DRNNS SANITARY Y_ N-
---KMAN
WORKMAN COMPENSATION DECLARATION ) RECET N
FD SCHOOL TAX Y_ N
.'
01 hereby affirm that I have,mrtl0cam mm of consent to elf-Inm a I RECEIPT N
certificate or Workers'Comperuatlonlmuranm ora rertifled copy tberto(l5ec.
3800,Tab CJ CAS EA. - N EIB PARK FEE Y_ N_
Policy N REC. M
Cam aey v-..rto nL-.G.�, CA F.4.SY R4(EA) 10BUILDINGDIVISI ON FEE
Certified copy bhereby furnished. GREASE/INDUSTRL IVASIEI P ANCHECI(FEE
EaCertlfiad copy b filed with the city inspection division.
CERTIFICATEOFIXEMPTION FROMWORKERS' GREASE TRA _ PAID
COMPENSATION INSURANCE
(This.eeion need not becomplemil lithe permit inforone,hundred dollars SEWER-SANTIARY-STOP.M F.A.200[rl'. Dat,
(51 I0)nify that
WATERHEATERW/VENT/ELECTR ENERGYFEE Y N
I mrtRy that In the performance of thework for which this Permit Is Issued,
1 shall nx employ any person in any manner so as to become subject to the WATER SYSIFA(/TAFAIING
worker:Compensation L.w.af California.Date PAID
Z Z Applicant NEW RFSIDFNIIAL I'LMB. SQlT. Dale RCcei t#
O
Z NOTICE TO APPLICANT:If,after oxides this Certificate of Exemption,you
Fshould become subject to the Workens'Comperwtiun provision.o(the Labor TOTAL:
fA Cade,you must forthwith comply with such provisions or this pemslt%hallM -' G
W ] deemed mvoked. BUILDING •E
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Ihereby af0unthat them Isa construction lending agency for the perform ELECTRIC FEE �-
Z a.ceuf the work for which this permit is Issued(Sec.3097,civ.C.) TOTAL: -
O O I<^dao some �r /,[ PLUMBING FEE.
LL I— Lendrr.Adere� J^' QTY. MECHANICAL PERMIT FEE MECHANICALFEE
O W I mrtiytLm l have read thb.ppl'atia^.nd state that theabove information
CIL bcoingtob ilding complywith and herebycounty henum r......nd state PERMIT ISSUANCE FEES IrA DP G
} rtlaingtobulldingcomtruction,and Mrebyauthprirn representatives of this -C7/lU—/JL-1/-pis/-
Z city to enter upon the abovcmFR
entloned property for inspection purposes. ALTORADDTOMECH.
(We)agme to save,Indemnity an d keep harmless the City of Cupertino ate Receipt#
V
against liabilities,Judgments,miss and expenses which may In mywayamue AIR HANDLING UNIT 9010,OD0 CFM) - SUBTOTAL:
.agaimtsaid Cltyl roue gr hung of this permit. AIR HANDLING UNIT(OVER 10,000 CEM) CONSTRUCTION TAX
Signatvrc of Applicant/ ontradpr Date F7(HAOST HOOD(W/DIKl) CONSTR ACTION TAX PAID:
HAZARDOUS MATERIALS CLOSURE 2 I 1 —Wg5,(z
Will the applicant or future building oovpa storeor haeme haaardcu. HEATING UMT(70100,000 BTU)
matcrial,s defined by tha Cupemro Municipal Code,Chapter 9.12 and the Date Roceit# e
i leak hand Safety Cad a Sactlon 25537(x)7 HEATING DMT(DVER[00,000 BTU) TOTAL: Oso
F-1ye, M No ur
Willunt Sppbcantorluturebuilding«cupindby the BuyequipmentAre.At vias VENTILATION PAN(SINGLE RFSIW ISSUANCE DATE
which emit hagements air cont.minanb a defined by the Bay Arca Air
• Quality Management District? MOILER-COMPpI-I'DR IOO,IXMI BTU) kAQ
1 ve Q No
haveraad teeth& et materials tions 25505, SS33 under and 25534.1
o! BOILER-COMP(OVER ID],00087U) 9
the GBandh Health building
code,nectloru25505,ve a tenant,that
EB 141991
understandthat lithe tithe c.p,nt net mrrantlyhaves which(,that itlimy h'LIVRio DFNTIAL MECH. 9Q.FT.
rmponsibility tp noii(y the ocmpant o(the mqulmments which must be rrct y
prior to Lwuanca ofd CartiflcateofOcevpanry. ni lane-. - �
�9 ems` 4}
Owner or authod agent Date
TOTAL: ISSUED BY:
OFFICE COPY