23976 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Address:
` /�F�^
os N L rte 0 ' 23L9
nename, one
'� A A
L4—,t 6A ITY OFCUPERTINO-BUILDING DIVISION
na man's Na Lie.No: APPLICATION it PERMITod-I r. 1pr"1,
�' 7 2 BUILDINGELECTRICALPLIIMBINGMECHAMCAL CATEGORY CONTROL q
Architect/ neer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address
Ire J PERMITISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION
I
he affkmthat l am Licensed under pcovWons of Chapter9(commsoc APPLIANCES-RESIDENTIAL -----------TUB ON�
ingwlth Seteon 9000).!Dlviion3ofthe Businessand ProfernmaCocie,and my �� 1
lfcenw Is In fu orae d effect. PANELS /♦�,��.�/�/s�Q� w Y -,
License Cuss CHITE-- � �_Y 1�✓Y'VfsJ I-wi\� t1./
Date_ ^sContrator CUk
ARCHITECTS DECLARATION OVER00 AMPS
q�v 0 C2C I understand my phra shag be used u public records. OVER 1000 AMPS SQ.Ff.FLOOR AREA 5/SQ.FT.
k z U Licensed Professional SIGNSELECTRICAL I {. 1
<�6 OWNER-BUILDER DECLARATION E ®
SPECIALCIRCUIT ��
,t.., , Ihereby affirm that l am exempt from the Contractor's License law for the /� r
p following reason.(Section 9(81.5,Business and Professions Code:Any city or `�I f,
OZF- TEMP.METER OR POLE INST. R 1
cauntrumum requlrna pemdttocowtmtiresth aprovgdemolbh,ormit to
any structuretaementhat hcorto Its cgaboreci pursuant to
fmsuchpeof to POWER DEVICES
file a signed statement that he b Ecensed pursuant to the proWiore of the
Q6 7 u,G Contractor's Licenee Law(Chapter-9(commencing with Section 9000)of Divi-
p�0� slon3ofthe Business and Profenions Code)orthathebexempttherefroon d SWIMMING POOL ELECTRIC VALUATI
Q
thebafor the alleged exemption. Any Wolatlon of Setlon 903L5 byre any ��O� CW
<•4 applicant fora permit subjects the applicant to a civil penalty of not more,than 0117i'E'IS'M77Ck{ESF7XTURFS
c. five hundred dollars($5001. NEW RESIDENTIAL ELECTR
p �n ❑I,as owner of the property,or my employees with wages as their sok SQ.FT, SLOW FS TYPE COh'STRUCTIOh'
k < C mpensatlon,willdothe work and the stmciure is not intended or offered for
�O sale(See.7064,Business and Profeselora Code:The Contractors License Law
j $ does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP
RES UNITS
who doessuch work himexelforthrough his own employees,provided that such
Improvements are not Intended or offered for safe.If,however,the build Ing or
improvement bsoldwlthinoneyearo(completiogtheowner- fiderwlllhave
th rden of proving that he did nor build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOODYDNE APN
L as or of the property,am exclusively contracting with...v d PERMIT ISSUANCE
contractors to rooxmet the project(Scc.90K Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN kVENT-WATER(EA)
WW,or Improves thereon,and who centrsts for such pxojets with a
TTILicensed pursuant to the Contractor's License Law FEE SUMMARY
J I am exempt undo Sec. B k PTC for this mason gAC((pLpW PROTECT.DEVICE
Owner pee DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
WORKMAN COMPENSATION DECLARATION RECE]I'IN
• [:]I hereby affbm that I have a cernflcate of consent to self-insure,or a F'0(TT1RF_S PER TRAP SCHOOL TAX Y N
certificateofWorkem'Compe gonImuranoracenified copythereof(Sec. RECEB7N
3800,Lab C.) GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
Policy Y S RECUT a
Com any GAEA.SYST[M-0VER4(FA)
[FCunifled copy Is hereby furnished. BUILDING DIVISION FEES
E]Certllied copy IS filed with the city inspection division, GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Ihi..etionneed not becompleted ifthepermit later..hundred doll.. SEWER-SANITARY-STORM FA.200FT. Date Remi to
(8100erdyts.) WATER HEATER W/VENT/FLECTR ENERGYFEE Y N_
1 cent that in,the performanceoftmanner forwhich as permit issued,
1 shag not employ any person in any manner. u to become sub' to the WATER SYSTEM/TREATING
workeni co non Laws of California Date' ^ — PAID
Z O soncbco esubfcato'sthe Workers
thissationlProvisions,
ro is Exemption,you NEV✓RESIDENTIAL PLMB.__SQ,FT. Date Remi tp
P shwlabemmesubjectto the Work en'such provisions;
porthiomof rmit s Lab he TOTAL:
W Code you must fonhwith comply with such provisbw or this permit shall be
or
W > deemed revoked. BUILD NG FEE
IL p CONSTRUCTION LENDING AGENCY SEISMIC FEE
= Z fhembyaf ,mthat there is a construction lending agency for the perform, TOTAL: ELECTRIC FEE
amu of the work for which thin permit Is busted(Sec.309],Civ.C.)
U O Lender's Name PLUMBING FEE
ly Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icenifythatlhavnm.dthis ppil.0onandaatethatthc Week,02"tlon �s
S brormt.l agree to comply withal]city and county ordlnances..d nate laws tAL
MI�DD
FEES PAID:
} N relating to building cominatlon,and hereby authorize represenlativn of thio
F Z city to enter upon the above-mentioned property for inspection purposes. ERCH.
— (We)agree to save,Indemnify an d keep harmless the City of Cupeneeo Date Receipt#
against liabilities,jadgmenb,mss and expense which may In anywayamme AIR HANDLING UNIT(to 10,000 CFM)
ryce
against said City in conecenof the granting of this permit. SUBTOTAL:
AIR HANDLING UNIT(OVER 10,(80 CFM) CONSTRUCTION TAX
S,S.w m of Appllc""Contr-chm Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZk RDOUS MATERIALS DISCLOSURE
Will the applicant" to building occupant stow or hand hazard00
hazardous HEATING UNIT 1 ,0008TU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the _ Date ReCel
I❑ yes safetyCod r,Se Joon]5532(.)7 HEATING UNIT(OVER 100,000 BTU) TO AT 7—
Will the applicant or❑future building occupant use equipment or devices VW17LATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havrdous ab contaminants as defined by the Bay Area Air
Quality Management DutriNo BOILER-COMP(3F1P OR 1W,IXtO BTU)
• have read the bazar eus materials requ lmmants under Chapter 6.95 of BOILER-COMP COVER 100,000 BTU)
the Gitand t Health k building
Code, et currently
25505,25533 a t and 25536. 1 Y
understand that if the building does not curzently havaatenant,that it is my NEW RESIDENTIAL MEIN.
respomibllity entity the occupant of the requbements which rwst be met f' a
' rmLssu ofa CertlRcate of Occupanry.
lir or author) agent pate O p w(9Z
ISSUED BY: i17 yG,
OFFICE COPY 'cr'I BNu
�1