21128 (2) APPLICANT TO FILL IN INFORMATION WITHIN'RED LINES - USE BALL POINT PEN ONLY 40-r2$
Buildin Project Identification 1 or PERMIT NO.
Building Address: 0. nal al f")Q
o a 6 -PC P L PTN I R
caner. ane: one; -
g_ CITY OF CUPERTINO-BUILDING DIVISION p
• tand N' r 0 -�-
ueNw: APPLICATION / PERMIT ( a
a` BUILDINGELECTRICAL PMtMBING-MDCFIANICAL CATEGORY CONTROL N
A gi Lie No:
�3 QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE I� [-1
LICENSED CONTRACTOR'S DECLARATION N LYJ
thereby a(firm that am licensed under provisions of Chapter9 Rommenc APPLIANCES-RESIDENTIAL LOB DESCRIPTION
Ingwl�S.f.1 vtsion3o(the Busln�m aandP%f�esslons Code,and my S FD I. 1L
licen--e I.s in(ul and died. PANELS K/
License Cl LIc.R
Date Contractor
ARCHITECPS DECLARATION 201-1000 AMPS
q�q�vw oc ZO❑ I understand my plans shall be used as public rmmi> OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
k o Uku Licensed Professional SIGNSELECTRICAL
OWNER-BUILDER DECLARATION 9'EC •G.7 //
7p � he byafBmn that l am exemptfromthe Contractor's License law for the
following reason.(Section 7031.5,Business and Professions Code:Any city or P L
p; F'Mq, county which requireaa permit to construct,alter,Improve,dernollsh,orrepalr
a anla,
ystmdure prlarto is Wuance,aborequirestheappilant for such permit W (o
W U file a signed statement that he licensed pursuant to the provisions of the
Ow Con3ofthe Ll� sand PChapt mCommenthathe hSedlon7emfmm nd
sion3ofthe Busmnsand lhofesslwru Code)orthat hebexempt therefromand SW[MMI ELECTRIC VALUATION
the basis for the alleged exemption. My violation of Section 70315 by any
O applicant fora permit subjects,the applicant to a civil penalty of not more than OUTL.ETSSWITCHESHXTURFS
five hundred dollars(9.500). l �Ja r
I,as owner of the property, NEW RESIDENTIAL ELECTR SQ.4T, RDEIFS TYPE CONSTRUCTION
Z< ❑ p party,or my employees with wages r]her sole
compenaadon,wllldolhe work and lhestmcture ls not Intended or offered for t
❑ alc(See7044,Bualnnsand Prafriadmo Code:The cmandors Lim.law
$$ docs not apply to an owner of property who builds or improves t hereon,and OCCGROUIs RES UNITS
who does such work himself orthrough hisown employees,provided that such
Improvements are not Intended oroffered foreale.lf,howevegthebuildingor TOTAL: r
Improvement bsoldwlthlnoneyearofcompleBoNthe owner-builderwill have
tl e�rdenol pmvingthathe did notbuild orlmprove forpurpossofule.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
U L as owner of the property,am exclusively cont-d-,with 11-n— PERMIT•ISSUANCE I•�L t
contactors to construct the project(See.7044,Business and Professions Code: CC
The Contractors License law doe.not apply to an owner of property who ALTER-DRAIN A VENT-WATER(EA)
builds or improves thereon,and who contracts for such ptojects with e
�q➢t(adads)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sac B A P C for this reason
•
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y NOUTSID�
FEES
Owner Date
WORKMAN COMPENSATION DECLARATION REOEET N
FIXTURES PER TRAP SCHOOL TAX Y N
❑I hereby affirm rkers that I have o Insurance,
ate of consent to self-finsure,ore RECEIPT X
3800,ab ofWorkers'Compematlonlnsuranaaaartl(led ropythereof(sec. CAS EA.SYSTEM-1 MICA OUTLETS PARKFRE Y N
3.00,lab C.)
CECa - GAS EA.SYSTEM-OVER4(EA) DING DTX
[ y BUILDING DIVISION FEES
Certified copy is herebyfamished.the
city CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified mpylsflled with the city inspection division.
. CERTIFICATE OF L)(EMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATIONINSURANCEfo SEWER-SANITARY-STORM EA.200L Date RCCCI t#
(0).rl.tonneed not be completed lithe pemdt ls(orone hundred dollars I tW
(4100)orfy that
h) WATER HEATERW/VENT/ELECTR ENERGY FEE Y N
Ianotemtathe perl moot(th work nnerforwhich mtobthbpemdtIs dtoth, —
I shall not employ any-Lawn In any manner eo m to become subject to the WATER SYSTEM/MPATING ,
Workere'Comperwtbn Iowa of California.Data PAID
z Z Applicant NEW RESIDENTIAL PLMB.__SQ.FT. Date RCcel t#
Z O NOTICE TO APPLICANT.If, Bla
,after nuking this Cerlteof Exemption,you
Hshould becnmerobjedtothe Workers'Compemalion provlsioruof the Labor TOTAL:
W Code,you=at forthwith comply withsuch provlslomorthb permit shall be DUILDING FEE
> deemed revoked.
1CONSTRUCTION LENDING AGENCY _ SEISMIC FEE Z
I hereby af0mnthat there is construction lending agency for the perform- ELECTRIC FEE
0 ansa of the work for which this pemNt is Issued(Sec.3097,Civ.C.) � TOTAL: t _
U Leader'sName PLUMBING FEE
LL F Lender.ACdre a - QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Iadifythat l have read thbappliation and satethat theabove Information T
1 Incorrect.Idgmatocomplywlth allcityand countyordlnanaaand state law, PERMIT ISSUANCE 12 (�'f FEES PAID'.
>_ CL to building commuction,and hereby authorim representatives of this
N
F U) city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADDTO MUCH. Date Reed t# qt7 1
� E (We)agme to uve,i emnilyandkremleas the City of Cupertino
agalrat lablWles,ja nh,ro�andcxwlwhtylnany aya AIRIlANDLINGUNITIT010,000CFM) SUBTOTAL:agalmtu consequ mnit. / e AIR HANDLING UNIT(OVER 10,000CIM) CONSTRUCTION TAX L
of App Contactor to EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
App
MATERIALS DISCI SU
Willtheappliant orfuturebulliingoavpant store or handle havrdous HFATINGUMT(TO 100,000BTU) Date RCCCI (# s
material as defined by the Cupertino Municipal Code,Chapter 9AZ and the
Health and Safety Coda Section 25532(a)T HEATING UNIT(OVER 100,DDD BTI- OTAL:
❑Yes ' M No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) DAT/E'5-
which cont haeardou.air contaminants an defined by the Bay Arca Air
• Quality Managementfkarict2 BOILER-COMP(3HPOR100,IXpETU)
Yea g APR 1 1991
4 No
have read the hawus materials requirements under Chapter 6.95 of BOILER-COMP(OVM 100,000 BTU)
the California Health A Safety Code,Sectloru 25505,25533 and 25534.1 /4r.^
and matand that if the building don not comentiy have a te"'n'that It I.my NEW RESIDENTIAL MECH. SQ.FT. Ctts/ 6
resporeibll ity to notify the occupant of the requirements which at be rret
prior to Issuance of a Certificate of Occupancy.
Owner or aulhonand agent Date ISSUED BY:�a—� �
TOTAL: s
OFFICE COPY