19785 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bvildin Pm ea Identification -
PERM T NO.
BuOdina Address: - (��f n
1 �0 � Y, Y1�� �e r,JC- Z� 9 / I8
wear•Name:, • /a Phone:
V ,OLI�(Y II�Y 1TRIL CITY OF CUPERTIN4BUILDING DIVISION ^ O
•��f�a^yey°� [�It(yA APPLICATION / PERMIT i�
�`• ' `�6�N ��1 s s BUfLDINGELECTRICAT PLUMBING- CATEGORY CONTROL
. Architect/Engineer. Lt.No: MECHANICAL'
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ,� ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
IMrcby afforn that l am licensed under provislonsofChapter9(rommene APPLIANCESRESIDENTIAL JOB DESCRIPTIONingwlth Se on7000)of Divlston3ofthe Susinessan Profeaio®Code,andmy
license lsinfu0 enddfecl. PANELS
Limme Tans Lk.M
DateUP TO 2DOAMPS
ARCHITECTContractmr RA 1
S E 7011000 AMPS
�+q+reOZ lunderstand my plaroelaBbe used as publicrerords. OVER 1000 AMPS 17 SQ.FT.FLOOR AREA f/EQ.FT. '
Licenses Professional SIGNS ELECTRICAL
Ff�d OWNCR-BUILDER DECLARATION
Z� a 01—
IherebyafRrmthatlamexemptfromthe Contnaor'•Llanxl.wfmthe SPECIALCIiCU1T/MLSC
o qqqq following mason.(Section 70615,Business and Protesons Code:Any city or
FZf'u( countywhich requlre•a permit toconatruct,alter,bnpowe,demelleh,compair TEMP.METERORPOLEINST.
3 anyswcture prlmtoit•laotance,also,requ(reathe applicant for such pemdHo
Ofile a signed statement that he k licensed pursuant to the provlsiota of the POWER DEVICES .
Cmuracce.Me.-.Law(Chapter 9(commencing with Section 7000)of Divi= SWIMMING POOL ELECTRIC
elon3 of thefludnea and Profealoro Code)orthM he V exempt there(romand0 VALUATION
the bash for the alleged exemption. Any violation of Section 7031.5 by any ..,�.
65 OUTLEISSWITOHF$E1s7URES
applicant for.permB•ubject•theapplkanttoativli penaltydnot morethan
flverundred dollars 55M. NEW RESIDENTIAL ELECTR SQ W TYPECONSIRUCTION
�n I,as owner of the property,or my employees with wages as their sole
rompen.atlon,will dothework and the.tructure b not intended or offered for
O sale(see 7064,Business and Profenioa Code:The contradoes Limme,law air
$ does not apply to an owner of property who bullets or improves thereon,and OCC.GROUP RES.UNITSwhodoessuchworkhm H.rth.ghhisownempluyees,providedthatsuch
improvement•are not intended oroffered forak.If,however,the buildlegor TOTAL:
improvement 6wld wlthinoneyearofcompletlo4theowne>bu0derwlll lave
t rden of proving that he did not build or Improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD TONE APN
L as owner of the Property,am exclusively contracting with licensed PERMIT ISSUANCE
commou s to o atmct the Project(Sec.7066,B-1hou.ami Profeaba Cade:
The CoNnctorb Llmna Law does not apply to an owner of propedy,who ,tib-DRAIN&VENT-WATER IFA)
W ads,or improves thereon,and who contracts for such ptojeRa with a
T(aclmW licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
I am exempt under Sec B&P C for this reason
DRAINS FLOG ROOF, SANITARY Y N
. Owner Date R RFA GOND.
WORKMANRECElIq
COMPENSATION DECLARATION S PER TRAP SCHOOLTA% Y N
I hereby affirm re
that I have•certificate of consent to self-insu , FI%TURF
m a
I ate ofWorken'Com rwtlonlaurenmoramdlFled copy threof e (Sec. RECEIPT•
W,lab C.) , , 1 ^'_ t�Cl CAS EA.SYSTEM-t INC4OU7LET5 - PARK FEE Y N PolicyIs Y��1 1l' U_ I GAS EA.SYSTEM.OVER 4(EA) RECEIPTM
Caany a—UI - - BUILDING DIVISION FEES
s`e!`Ijed copy b herebyfurnished.the city CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�1Cortlfied copy d(IW with the city Inspection division.J3���� CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP ,PAIDt-19*C' ¢hf�'_a�1s4~�'
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 2t00FT Date I( ced i t# r/
(TMsseRlon need not be completed lithe permit isfmom hundred dollars
(S100)or loss.) WATER HEATER W/VENT/ELFiCTR 'ENERGY FEE Y N
I ceditythat In the performance of the work(orwhich this pemdt is issued, —
I shall nue employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation laws of CxIBomlu.Date PAID
C• Z Apphant NEWRESIDENTIALPLMB. SQFT, Dale fiscal IN
Z O NOTICE TO APPLICANT.If,after nuking this Ceriflatenf Exemption,you
should become subject to the Wmrkers'Compemation provblom of the Labor TOTAL:
V) Code,you=at forthwith comply with such provhlore or this permit shall be Od
> deemed revoked. — 13LJILDING FEE
W
C CONSTRUCTION LENDING AGwCY SEISMIC FEE
I hembyafOrtn that there is a construction lending agency for the perform ELECTRIC FEE
M Z ance of the workfor which this permit is.^,ad(Sec.3097,Civ.C.) TOTAL:
V O Lender's Name PLUMBING FEE
LL F Lender.Adarea QTY. MECHANICAL PERMIT FEE MECHANICALFEE
O W lomifythAlhavereadthlsappliatbnand statethatthe above Information
1 reatiis ect.baileeto gcomplywith o,andhembyaty and untyLzerepncnmastsofthi. PERMIT ISSUANCE FEES1 —PAID � 2
} N city to gtobupont a abowction,anaheprop property
otlmreptio npurposo(thle Jes r_I'YD v 5r
Z cityWenter
ee to sae,indemifyan d propertymess to Cit of Caperses ALTEROR ADD R7 MECH.
— inse)agree to ave,Indemnify an a keep harmless the City of Cupertino Date ReO L
against Babdifies,City ydgnequems,"sand expenses which may In enywayarorue AIR HANDLING UNIT(TO 10,000 CPM) SUBTOTAL:
against said city In coneequeor the granting of this permit. AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature mApplicant/ContractorDate EXHAUST HOOD(W/DUCD CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant-t.m.thandl,hazandods HEATING UNIT(70 IOD,ODO BILI) Daft Recei tN
material as deflr d by the Coperloo Municipal Code,Chapter 9.1$and the
I ealth and Safety CoQ�,Jtlion 25537(a)7HEATING BTU)
rl Yes
, mNJ7lf '
TOTAL:
Wllitheappli �a
VEMILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Maaga.etstrict? BOILER-COMP OHPOR 100,000 BTU)
4Ya No r7
haye read lM1e M1ar a materials requirementsunderChapter6.95 of BOILER.COMP(OVER 103,000 BT ) 2�2 / _
the California Health&Safety Code,Sections 25505,25S33 and 75534. 1
understand that lithe building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQFI'
responsibility to notify the occupant of the requirements which most be met
-PWcjaF.0 n W.Cedlf ionic ccup..cy. -
nerora alhm Ire3 Akent Laic ISSUED
TOTAL:
OFFICE COPY .