24144 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —,USE BALL POINT PEN ONLY
Building Project identification - PERMIT h'Q,
Building Address: Z
w era4144
arse hone: APPLICA 11ON SUHMI 1-1 AL DA IE
1715 CITY OF CUPERTINO-BUILDING DIVISION Q .� �M
+� Contractv'. y2Li6 Y APPLICATION / PERMIT . u—K r�-
BUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL
Architect neer: Llc.No:
' `' ; UILDWGPERMIT.INFO,
gT4't. ,ELECTRICPERMIT °'i�FEE ',
Address: Z Q - yv 3� -ZPERMITISSUANCE
LICENSED CONTRACTOR'S CLA TION
Iherebya(frmthat l are licensed under provisions of Chapter 9(commenc- APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwith Sedion700D)of1Rvitl=3ofthe Busineasand ProfessionsCode,andmy l
license Is In full( and died. 6 Cf 2_ PANELS j�rn� / G"1 J�l�al
L=CI. Loc.p -1 'I ll..Ilr Ir r� _ .,
Date turachar IT IQ 200 ANTS
ITECr ECLA A ION 201-IMO AMPS
pOtZO I understand my plans shag beused as public records. - - OVERIMOAMPS - SQ.IT,FLOOR AREA $/SQ.FL
ILu(/ Licensed Professional SIGNS ELECTRICAL - '
.OWNER-BUILDER DECLARATION SPECIALCIRCNT/MISC
I hereby affirm that[am exempt fromthe Contractors License Law for the
ZO F
cmntywhichmquimsapermittommtmd,alter,improv demolleh,ormpalr
following reason(Section 7001.5,Business and Professions Code:Any city or TEMP METERORPOLEINST. _•
Kg
�a G anystructure Inform its Issuance,alsorequirestheappl[cant forsuch permit to POWER DEVICES
c.O file a signed statement that he Is licensed pursuant to the provisions of the '
FSOaContradors License Law(Chapter 9(commencing with Section 7000)of Divi- "-i
sun3 ofthe Busineas andPmfemloru Code)orthat he is exempt therefromandMING IDOL ELECTRIC \ 1_- iVA4 AT3 N
J the basis for the alleged exemption. Any violation of Section 70315 by any
applicant fora permit subjects the applicant toa civil penalty of not more than OUTLETSSWITCHESFIXTURES � '� j
five hundred dollars($500). C•I „'� u y '_'
❑I,as owner of the roe NEWRESIDENTIALELECTR SQET, STOIUESCONSTRUC ION
property,rty,or my employees with wages as their sok A f E:; /
2¢ compensation,will do the work,and the structure R not intended or offered for -
O In(Sec.7044,Buenas.and Professions Code:The Contractor.License Law
does not apply to an owner of property who builds or improves thereon,and �
CC.. whodoessuchworkhm l(orthmghhisownemployeesprovidedthatsuch OCC.CROUP RES.UNITS
improvements are not intended mattered for sale.If,however,thebuildlegor
Improvement issold within one yearofcompldion,the owner-builderwlll have
it Men of proving that he did not build or improve for purpose of sale.). QTy; :"c p1y[Jjy1BIN GTEAMI', FEE'.-. FLOOD ZONE APN
Lj I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to constm t the project(Sec.7044,Business and Professions Code:
The Contractor's License Law does not apply to an Owner of property who PETER-DRAIN&VENT-WATER(EA)
Wilds or improves thereon,and who cod
ntracts for such pkojes with a
reder(s)licensed pursuant to the Contractor's License Law. FEE.SUfARY
IJ I am exempt under Sec. B &P C for this reason BACK FLOW PROTECT.DEVICE OUTS OF FEN
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N
WORKMAN COMPENSATION DECLARATION RECEIPT N
' P ❑I hereby affirm that I have a certificate of consent to self-inure,or a TURES-PER TRAP SCHOOL FAX Y N
cenilealeofWorkem'Compemationlmumnmoracenifledmpythereof(Sec. .. I RECEIPTM
GAS EA.SYSTEM-]INCA OUTLETS
3800,Lab CJ PARK FEE Y_ N_
Polity# dam. �d GAS EA.SYSTEM-0VER4 ETA) RECEIPT#
Com any BUILDING DIVISION FEES
❑pCertifed ropy is hereby famished. GRCASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
MtertlBed copy is filed with the city Inspection diaigon.' '
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SAMTARY-STORM FA.200FT. Dat 1 I#
(Thissedlon need not be completed lithe permit Is forone hundred dollars
($1�)Nfy that
WATER HEATER W/VENT/ELECTR ENERGYF
I certify that o the performance aof ny
m work for which this permit Is Issued,
I shall not employ any person In any manner m as to become wbject to the WATER gYSTEM/TRFAIlNG
' Workem'Compeneatlon laws of California. Date - PAID
O Z Applicant - NEW RESIDENTIAL PI.MB. at Recei [#
Z O NOTTCETO APPLICANT:If,after makingthisCertlfcateof Exempflon,you SO•ET•
should become subject to the Workers Compereatlon prov,k ne of the Labor TOTAL:
W Code,you must forthwith comply with such provisions or this permit shall be
j deemed revoked. B G FE
W
G CONSTRUCFIONLHNDING AGENCY (SMI
Ihercbyaork forwhichtisamnstmdlon leadfirgagency the perform TOTAL: ELECTRI
OQ Z . ance Lenderthe work forwhlch this perMtis Issued(Sec.3097,CIv.CJ PLUMBINGF
O Lenders N.
ly H ndersAddre�� QTY:' IVIECI'ANICAI ,O.ERMIT FEE' MECHANICA FEE
O W Icertify thatl havereacithisapplicationand statelhAthe above information
Is correct.l agree to comply with all city and county ordinances and date laws PERMIT ISSUANCE FEES PAID:
} S relating to building conctrudion,and hereby authorize representatives ofthle
(— Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. Date Recei f#
— (We)agree to save,Indemnify an d keep harmless the City of Cu pertlno P
against liabilities,judgments,costs and expenses which may In any way acerae AIR HANDLING UNIT(TO 10,000 CFM) - SUBTOTAL:
agalruteelCGT tmmmsequ of the grant Ing of thls L
�f' Z Z— AIR HANDLING UNIT(OVER 10,000CF, ) CONSTRUC ON TAX
Staof Appi t/Co actor to EXHAUSTHOOD(W/DUCT) CONSTRU ON TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous , HEATING UNIT(TO 100,000 BTU) Data RBCBI I#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
Iicalth and Safety Cod Ion 25532(a)P HEATING UNIT(OVER 100,000 BTU) TOTAL aa..—�
❑ Yes No
Will the applicant or lu re building occupant use equipment or devices VENTILATION FAN(SINGLE RESID)- It DATE
which emit hazardous air to Lin as defined by the Bay Area Air
Qr (icy Management is d7 BOILER-COMP OH['OR 100,000 BTU)
Yes
o
4havereadthehaza ousrnaterialsmquirerr'entaunder Chapter6.95of BOILER-COMP(OVER 100,000 BTU)
the California Health&Safety Code,Sections 25505,25533 teand 26534. I DEC �OJG
understand that if the building does not currently haves nant,that
it is my NEW RESIDENTIAL MECH. SQ.FT. r
responsibillty to notify the occupant of the requirements which must be met
o issuance ofa nl(icateof0cmpancy.
_ Z� GlI1 Ur CUmn4
ne oraut ori d agent ate '�+`�"
ISSUED BY:
TOTAL:
OFFICE COPY