20440 (5) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONVi
Building project Identification /( a{/) ) PkRMITNO.
Building Address: u~JL 1 �� � 2 0 7 7 5
weer• ares one: A A A
CITY OF CUPERTINO-BUILDI GDIVISION
• co .r �: Lic.No: APPLICATION /PERMIT [(/
inc, BUILDING-ELDCTRICALPLUMBING-MECHANICAL CATEGORY CONTROL a
Arcs 'neer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address
LICENSED CONTRACTOR'S DECLARATION
PERMITIS5UANCE ❑ ❑ 1:1Ihe7that Ia under proofC9c APPLIANCES JOB DESCRIPTION
IngwithSectionOOO)ofDivisio3oftheBusinessland ProlssionsCvde,and
my
license is In f ddlm. C PANELS
License Cla Lk.N M �p
nate y lam ^ cono-aRnr - � IL
LIe✓` CHITECPS DEC ON rV I 201-1000AMPS
niz I understand my plans shall be used as W public records. OVER IOAMPS SQ.FT.FLOOR AREA $/SQ.FT.
HE Licensed Professional SIGNS ELECTRICAL
6<w OWNER-BUILDER DECLARATION
SPFGIALCIRCUIT/M
owing .. lhatiam0I.S.Business fromthe Contractors Llanx Law fort he
f ntygreason.imlon7 ttomtmdandrimp ons Code:Any cityorp l:, TEMP.MEIFROR EINSf.
countywhkh requlresa Permite,alsorquirestheapmvgdemolsh,orrepalr
ray atrvrnrrepdortoitshwan=,aso sed pursuant
to the (.visionor such of Lm POWER DEVI
cG Q V file a signed statement that W s licensed pursuant to the provisions of the
Contractor's LicerseLaw(Chipter9(=mmencingwith SrcBon7000)of Divi- SWAIMING LELECTRICVALUATION
mOs sion3ofthe Businnsand Profewbm Coae)orthathebexemptthemfromand
the boas for the alleged exemption. Any violation of Section 7071.5 by any OUTLE TCHESFI%TURES
applicant fora permit wbjms the applicant to a civil penalty of not morethan
c Rve hundred doll..(SM. NEW ESIDEN77ALELECTR
l,asownerofthe ro SQ Fr
STORIES TYPE CONSTRUCTION
k P 6 compensation❑ F FrtY.or my employees wltA wage as their sus
,will dothe work and thestructure s not Intended or offered for
O sale(Sec 70th,Business and Profego..Code:The Cmdo'does License Taw
g does not apply to an owner of property who Wilds or improves thereon,and �gQC.GROUP R .UNITS
who doessuchwork him elforthrough hsownemployem,provided that such
Improvements are not intended oroffemd forsale.If,however,thebullding or TOTAL:
Improvementswldwithln oneyearofcomplctiogtheowner-builderwill have
trye�trdeo of proving that he did not build or improve for purpose ofsak.). QTY. PLUMBING PERMIT FEB
LJ L as owner of the property,am exclusively contracting with licensed FLOOD"LONE APN
PERMIT ISSUANCE
contract..to mmtmd the project(Sce.7044,Business and Professions Code:
The Contractor's License Taw doss not apply to an owner of property who
ALTER-DRAIN k VENT-WATER(EA)
coOds t r Improves thereon,and who mnt.m for wN p(ojms with a FEE SUMMARY
ryp]Iamsexempt under
Settothe Contractor's License Law. BACKFLOWPROTECT.DEVICE
LJ 1 am exempt under Sec. B k P C for ms reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEIPT'M
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAX Y_ N_
❑1 hereby affirm that I have a certificate of consent to self-Insure,ora RECRIPr M
certillcateofWorkers'Compereatl;losuranm ora=rtl(Ied ropymereo((S=. GAS EA.SYSTEM-1 INC.40 5 PARK FEE Y_ N_
3800.Lab C.) /� !� ` D, /-7
�, Poliryp 1, — .� 17 l ! RECmTX
Co any / EA.SYSTEM-0VERd ) B U ILUING DI VI SION FEES
M-ified copy s hereby furnished. EASE/INDUSIRLW INTERCEPTOR PLANCHECKFEE
(� ❑certJea copy s rued wire the sty Int ren div at, .
CERTIFICATE OF ECEMPFION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWERSAN)T -STORMEA.libi Date Rel i 1#
(Thssmion need not be completed lithe permit is for one hundred dollars
(SIW)orlessJWATER I{Fls W/VENT/ELI:CTR ENERGY FEE Y_ N_
1 — imnlfythat in the pedornan<co(thework for which the permitsssued,
KlJ I shalt not employ any person in any runner so as to become subject to the
Workers Compensation Laws of CalB.rns. Date WATIR /TREATIN'G PAID
licant
Z Z NOTICE TO APPLICANT.If,after making the CertBlcateof Exemptien,you NE'W DENTIAL IafMB. SQFr. DRIC Recef t#
O should become subjm to the Workers C.mpersation provsioro of the Labor TOTAL:
fA Code,you must forthwith=reply with such provisions or this permit shall be 13U1 DIN
G FEE
deemed revoked.
W
CONSTRUCTION LENDING AGENCY SEISMIC FEEF
d Thereby orkfor
hatrw there lea=mtruRionlending(Ser. agenry .C) perform TOTAL: ELECTRIC FEE
� Z anrdee.of Name
—rwhkhths perMtsssued(Sec.3097,Cis.C.) PLUMBING FEE
LL O Tenders Name
LL IcndsrsAddrex Tv. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I=oft. thatl Iagree to c rcadmsa all
citynand dcounty hat ordinances and
Q. s=rt.ct.Iagrre to comply with all cityand=untyominanmand state taws PERMIT ISSUANCE � PEES PAID:
>. relating butiring
=mtructlon,and herebyauthorlurepreantativeaofthis aVV
I— Z dtyto er Up.nmeaWve- nttoned property for inspection purposes. ALTER OR ADD TO MECH. Dale Receipt#
(W gree to save,In ren and k=p harrelex the City of Cupertino
V gal billtien,pdgme is, sajru nde penan which may in anywayyyyyyaccrue AIR HANDUNG UNIT(TO 10,000 CFM) SUBTOTAL:
mei`In cons a of the anti. this permILn�7 AIR HANDLING UNIT(OVER t0,000CFM) CONSTRUCTION TAX
C((((( CONSTRUCTION TAX PAID:
of
.q.. Ap ican/Contractor44 Date E)(FIAUS'r HOOD(W/DUCT
HAZARDOUS MATERIALS DIS RE
Will the applicant or fumm building occupant re handlehazardous HFATING UNIT(TO 100,000 BTU) ----bate Receipt#
nuterul as defined by the Cupertino MurdcipalCode, apter9.lZandthe
Health and Safety Code Section 2553Ha)P HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes [n No
Will the applicant or future building occupa useequtperentordevim , VENTILATION FAN(SINGLE RESID) , T� ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air �i
. Q.ralityManagement District? BOILER-COMP OHPORl00,000BTU) ,}UL,2.71990
Ej No
haYes ve read the hazy .us materiae requlremens antler Chapter 6.95 of BOILER-COMP(OVFR 100,000BTU)
the California Hmlth k Safety Code,Sections 25505,75533 and 25534. 1
understanathatifthe buildin docs not currently have a tenant,that it is my NEW RESIDENTIAL MECH. .FI'
SQ .
r.p flityton.tifythe ant.ft requiremsmswhiehrrwstb ril}t�l} I'}. ClIruifBQ
tante of a Cert k, fOc= aney.
O.vner.....rodzed agent ate (�� ISSUEDBY:�• 6 I7
TOTAL: Iv
�— OFFICE COPY