20243 (4) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification VnbLGo 141,w Hk PERMITNO.
Bu Bre
dn�2dd ,,:N .N oL t 20243�cD ., S�I, ggs ,Na o„�
VV 33 hone CITYOFCUPERTINO-BUILDINGDIVISION A A
C tractor's Name: ,Y Lie o: APPLICATION /PERMIT e
edza- `SS BUILDING-ELECTRICALPLUMBINC-MECHANICAL CATEGORY
Architect/agloar. I Lit,No:
A1144d—l ” lh&ff �n QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addmss: ' 0' IVJ91 7N(6 Uri, PFRMITISSUANCE ❑ ❑ ❑
m
LI . CF
NSEDCONTRAOR'SDEC RATION q((/,x� -
I hereby affirm that l alicensed under provisions of Chapter9(commen APPLIANCESRESIDENTIAL JOB DESCRPI'ION
Ingwlth Sect(on7000)of DiWs(on3ofthe Buslncsand Pmfe =s Code,and my
license la In fullfora and effect PANELS
License Clas LicaLT` \—
Date Ctmmactor v
ARCHITECTS DECLARATION 701-1000 AMPS
q�+ocI understand my plans shall be used.public records. OVERIOOOAMPS SQ.pr.FLOOR AREA $/SQ.FT.
00
ie UF, Licensed Professional SIGNSELECTRICAL •7(-,a� �r
< OWNER-BUILDER DECLARATIONlhateTom-sT'!7"� �Or ��
�n "qcee SPECIAL CIRCUIT/MISC
L, owing raf@mthatlam31.5,B(ro ossa Contractsions Code:Law fort he
Fg7 follow(ngreasmquimsapeon 3ttoco tmdand Pimp .me=te hnycity ormpair TET,.(p,METIA OR TOLE INST. 7 �(/ x
anystm�ntympriorlreiapwa ttoc.vtuuimtheapromntforsuch, er tto Vu
�YY Q
any structure patemenbhat he Is ohoredpursuant to the provisions
t e POWER DEVICES
C�U file a signed statement that M Y licensed pursuant to the provisions of the
Contractors License law(Chapter 9(commencing ncin with Section 7000)of Divi- VALUATION
w ss B SWIs1MING POOL ELECTRIC
O Yon3of the Business and ProfsalonsCode)orthat hes exempt therefromand
p~ Sn S the bash for the alleged exemption. Any violation.f Section 7031.5 by any OUTLETSSWITCHESHXRIRES
applicant fora permit subjeceathe applicant a civil penalty of not enrethan
Cc � � five hundred dollars($5M. NEWRESIDENTIALELECTR SQF7. SLOW TYPE CONSTRUCTION
.. �1l as owner of the property,or my employees with wages as their sole
kit compemafion,:21 dothe work,and thestructure is not intended or offered for
O Cela(Sec.7044,Business and Professions Code:The Contractors License Law
1;7 5 S does not apply to an owner of property who builds or improve thereon,and OCC.CROUP RES.UNITS
a who does suchw.rk himself or through his own employees,provided that such
improvements are not intended or offered for sale.If,however,the building or TOTAL:
improvement Esold within one yearof completion,the owner-builder will have
t Nen of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
184 v owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
tractors to construct the project(Sec.7044,Business and Profesbns Code:
The Contractor's License law does not apply to an owner of property who
Wilds or improve Uaeon, and who contracts for such ptelacb with a ALTER-DRAW&VENT-WATER(EA)
PIcm4s)licensed pursuant to the Contractor.License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
a exempt under Sec B &P C for this reasonOUTSIDE FEES
Own Date DRAINS FLOOR ROOF,AREA,GOND. SANITARY RECEIPT
WOR KN COMPENSATION DECLARATION p0(TIJRES PER TRM SCITOOL TAX Y_ N_
❑1 hereby affirm that I have a ecrtllate of consent to self-Insure,or RECEIPT N
certificate ofWorkers'Compensation Insurance or a artified copy thereof(Sec.
380),lab C.) S GAEA.SYSTEM-t INC.4OUTLETS PARK FEE Y_ N_
Policy p EA.SYSTEM-OVER 4(FA) RECEIPT 0
Com any RUI LDING DIV]SION FL LS
�Certiied copy IS hereby W red,hed. EASE/WDUSTRL WASTE INTERCEPTOR PLANCI-IECK FEESS
�Ceri ied copy b filed with the city Inspection division.
CERTIFICATE OF EXEMPT ION FROM WORKERS' REASETRAP PAID S1so {J�z F�r°a
COMPENSATION INSURANCE SEWER-SANITARY-STORM F.A.200FT. Date RCmI t#
(Thissectlon need not becompleted if the permit lafor nehu dollars
(slln)or lea+.) WATER HEATER W/VENT./F3,ECTR ENERGY FEE Y_ N_
I artifythat in the per(o sof the wakfor wMch rmitlatarou
I shall not employ any pe 1 any rtanner n ns to become aabject to the W, EATING
Worker%Compensation laws llfornb. Date PAID_J_L_l SSM_
0 Z Applicant R D LPLMO. SQ.FT. Date Remi t#
Z NOTICE APPLIC ,after trading this Certificate of Exemption,you
shouldVyfb'
' trot a darn Compereation provisions of the Labor TOTAL: _
� W Code, rt with comply with such provisions orth perms. BUILDING EE
W ] IS CONSTRUCTION LENDING AG�NyCYSEISMIC FEE
athatthere&am to on to III uy( t rfornv TOTAL: ELECTRIC FEE
7 Z arrv.fthxw.rk forwhichthia permitsblued(SedV3o' Civ. .
(� O_ Indere Name PLUMBING FEE
LL F Inder.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O Icortlythat l lave read thisapplloUonand state thatthe above Information FEES PAID
O W bcomet.Iagree to complywith all city and county ordinances and Yate laws PERMIT ISSUANCE
>. a relating to building construction,and hembyauthorturepresenlativeaafthis
(_ Z city to enter upon the above.reentioned property for impaction purposes. ALTERORADDTOMECH. Date Receipt#
(We)agree to save,lndemNty an d keep harrelain
sse the City of Cu pen .
V agabat liabilities,Judgments,ones and expenses which may In any way am /dR HANDLING UNIT(7010,000 CFM)us SUBTOTAL: O
ago Wt u� ity In consequence13 f the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXtIAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Reeef t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
licalth and Safety Cade Section 25532(a)7 FIEATING UNIT(OVER 100,000 BTU) TOTAL: 3 11.43
❑ Yes M No
Wllllhea ppllont or hIm.building occupant use equipment or devices VENTILATION FAN(SINCLE RFSN) ISSUANCE DATE
' which emit haardousabcontamimts as defined bythe Bay Area Ale
Quality Management District? BOILER-COMP DHPOR 100,000 BTU) PAM D.
'?ye, QNo
i� have read the hazy ous materials requirements under Chapter 6.93 of BOILER-COMP(OVER 100,000 BTU) JUN IL's y IJJV n('� I
the Calif orniaHealth&Safety Code,Sections 23505,23533 and 25534. I
understand that lithe building dos not currently have a tenant,that it b my NEIN RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requirements which meat be out p ,y
prior to Issuance ofaCertiOcate of Occupancy. City of Capeeflno
Owner or authorimd agent Data TOTAL: ISSUEDBY: �]
OFFICE COPY