20482 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identlfleation - PERhRTNO.
Building Address: A 0
asoo 2, G- 20482_
v—
tiers arae: one. A A A
01&-/774-L CITY OF CUPERTINO-BUILDING DIVISION _ �B
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Cnntrannr'aNam:: LIc.N.: APPLICATION /PERMIT S CU ,,) ELEC /C- 12 L143 BUILDINGELECTRICALPLUMB1NC-MECHANICAL CATEGORY CONTROL#
Architect/Engine Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLOC
Address: �� //£,L r✓ PERMITISSUANCE /J..,qCy ❑ 4K 11 ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(comrtumc APPLIANCESRESIDENTIALJOB DFSCRIITION
ingwith Sect1on7000)of Division3ofthe Bminessand ProfessionsCode,and m
license Is in full force and effect. PANELS
License Date-5 ss —/QLic# /_7 3 7 �SO0 .�
Date Contractor U AT/N L£(' UP TO 2DOAMI)S, 701.1000 AMPS
ARshallW used
as pu RATION OVFRIMAMPS SQ.FT.FLOOR AREA $/SQ.FT.
gippp±±re0 O I understand my plana shag W used a public records.
E Licensed Profeeslowl SIGNS ELECTRICAL
<<�Q OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC
H � Ihembyaffirm that l am exempt from the Commerce's License Law for the
Z Q t- following recon.(Section 7031.5,Business and Professions Code:Any city or TEMP.METER OR POLE INST.
q�p county which requires a permit to contrun,alter,Improve,demolish,or repair
n anystmcture prior to its issua oce,a Lao requires the applicant fee such permit to POWER DEVICES
asWb�Wb� `O file a signed statement that he b Ilmosed pursuant to the provlaloro of the
30�^ slon3a(thesBulcense Law s msand(Profe WmCWe)orhat helth lsexemonthe�refromind —S VALUATION
IDOL ELECTRIC VALUATION
P
�^ the bean for the alleged exemption. Any t to
of Secpenalty
701.5 re any .00
�S Q$ OUILETSSWITCHESITXTURFS
applicant fora permit subjects the applicant to a civil penalty of nor morethan
five hundred dolls.($5M. NEW RESIDENTIAL ELECTAFT.
F]1,as owner of the property,or my employees with wages as their sole �' STORIES TYPECONSTRUCTION
�7aa compensation,willciomeworkandthestructure isnot Intended or offered for _ SOT hp7-p •00
'S 0 p sale(Sec.7WE Buslncm and Profealom Code:The Contranars Llceme Law
does not apply to an owner of property who builds or Improves thereon,and l OCC.GROUI' RES.UNITS
whodoasuchwwkhlnseltmthrough hisown emplo5me,provided thatsuch ���s1
Improvements are not Intended oroffered forsale.If,however,thebullding or \TOTAL: 40 , 0
Improvement bsold within one ra rofcompldion,the owner-__.1__z_111___
tlffrden of proving that hedm nmbundorlmprove forpurposeofsale.). QTY, PLUMBINGPERMLT . FEE FLOOD ZONE APN
LJ I,as owner of he property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7014,Business and Professlona Cade:
The Contractor's Llmnse Law does not apply to an owner of property who ALTER
Wilds or improves thereon,and who contract for such pro"with a RAIN&VENT-WA1'Qt(EN
gqNpI(Tactw(s)licensed persuanttothe Contractor's Lldense Law. BAER W PROTECT.DEVICE `-1t, FEE SUMMARY
cLfl am exempt under Sec B k P C for this reason 'FEES
•
DRAINS ,FIR ROOF,AREA,CDND.� SANITARY
Owner Date RECEIPTX
WORKMAN COMPENSATION DECLARATION FMURE x"TRAP Q SCI 1001,TAX Y_ N_
❑I hereby affirm that I have a certificate of consent to uB-Inure,w a RECEIPT X
certificateot Waders Comperoallonlmuranmoramniftedropyhereof(Sec. (' \ 7\
3800,IabC CAS F.A.SYSfEI.i-1 IN C.40IITLETS '1 d 1 ! PAItI(FEE Y N
Poli)X lJ RECEIPT X
Cam anv n 9A/bt(' Tj,J/1 GAS Iv�ST14_OVEfNDEA) a BUILDING DIVISION FEES
�CeAlfied copy he hereby furnished. CREASE/INDUSTRL WASTEI TnR�j PLANCIiECK FEEPG Cvnitied copy b filed with the city Inspection division,
)W GREASE TRAP J `s PAID
-
COMPENSATION
OF IXEMPTION FROM WORKERS'
COMPENSATION INSURANCESEWER-SANITARY'STORM FA 200" Date Rcmipt#
(Thissecilon need not W completed If the permit is foron hundred dollars
(S10W or Ica.) WATERHEATERW/VENT/ELECTR ENERGY FEE Y_ N_
I certify that In the performance of the work forwhich this permit b issued,
I shall not employ any person In any manner n as to become subject to theWA.��,�i/.UI�.D
Workers'Compemmion Laws of California.Date NG PAID
NPOIICE TO APPLICANT:ILaftor making this Certificate of Faemptlon,you NEW RESIDENTIAL PLMB'plicant `.QJ-7 Date Remi t#
Z Z
2 should become sub)ect to the Workers Compematlon provisions ofthe Labor TOTAL:
FV) Code,you most forthwith comply with such provialom orhis permit shall bo BUILDING FEE
LU j deemed revoked.
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Ihembyaffireethat there Is a construction lendingagen)forthe perform TOTAL: ELECTRIC FEE �.0
7 Z ante of the work for which this permit b bsued(See.3097,Civ.C.)
(� O l.nder'a NzPLUMBING PEE
me
Lewers Address QTY. MECHANICAL PERMIT FEE MECHANICAL PEE
OW Icertify lhail have read thlsapplicatlonand gatethattheaWve Information
EL boomed.Idgmetocomplywithallcityand county ordlnanmand gate paws PERMIT ISSUANCE FEES PAID:
>. relating to building comtrucron,and herebyamhorice epresentativesofthis
(— U) chyto enterupon the above-mentlond property for inspection purposes. ALTERORADDTOMECH.
(We)agree to ave,Indemnify an d keep harrNess the City of Cupertino Date Receipt#
V ago labllilles,I dgments,cogsandrxpvrscswhtc mayte.nywayamme AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL:
a Inst old City In conaryuen of the in of s It.
S AIR HANDLING UNIT(OVER 10000CI'M) CONSTRUCTION TAX
Sig reof Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIAL DISCLOSURE
Ill the applicant or future build Ing occupant store or handle haeardous HEATING UNIT(TO 100,000 BTU) Date Recel t#
material as defined by the Cupertino Municipal Code,Chaptcr 9.1Z and the
IIMth and Safety Code 25537(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
r-1 Y. M No
Will the applicant or tuturebuilding occupant use equiprnnt or devices VENTILATION FAN(SINGLE RESID) 1$9ADATE
which emit haeardom air contaminants as defined by the Bay Area Apr
Quality Management Dbtrl BOILER-COMP C311POR 100,000 BTU) 0199Q
❑Yes e UAY 3
.' Ihave sad the hav cases materials requiements under Chapter 6.95 of BOILER-COMP 100,000 BIU)
the CaliferNa Health k Safety Code,&pion 25505,75533 and 75534. I
understand that It the Wilding does not corently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT. ^.iy of CUpethno
res mibilitytonatifythemmpantofthemquirc este which most be mot k
for oiv.srce of Cc it' to of0 anry,
S1?o /I1
Zee or authodud agent Uate TOTAL: I,SSUEDBY:4` x Q Cv
(Y's,
OFFICE COPY