20281 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Suilding protea identification PERMIT NO. 1
Building Aaare:.,:
Lo M ITA. 20281 0 n O 1
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3644tJ WAbA IS CITOFCUPERTIN -BUILDING DIVISION
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Contractor's Name: Lic.No: APPLICATION'/ PERMIT 1
THoHA PLWAG 35(c,0140 BUfLDINGELECTRICA nUMBINGMFL MCAL CATEGORY CONTROL#
Architect/Engineer. Lic.No:
aa�� QIY ELECTRICPERMIT FEE -BUILDING PERMIT INFO+
Address:30s i E s W fa��SFLI NErTDA) ke
PERMITISSIJANCE ❑ 1:1 ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm
on700dofDiv licensed oftheunder prwland Pro Chapter9(commenc- APPLIANCESRESIDENTIAL JOB DESCRIPTION
ingwlth Section7000)of Dlvbion3.fthe Buslnessand Professi.nsCode,and my
li...isinfu�yf. andeffect. PANELS '{�
License Chss` Lic.p__ V // L
DateC�ITI Qrl_CHIT1C7r �11C fY' (%VK_]l
Tc ARCHITECTS DECLARATION '�4'7 OVER00AMP5
�2 I understand my plana shall be used as public remrda OVER 1000 AMPS SQ.IT.FLOOR AR 5/SQ.FT.
.0 O SIGNS ELECTRICAL'
cG V�j Licensed Professional
z
`<<Fi� OtI am oBUILDERDECLARATION
N] i '
i.. 7 I herebya(fimn that I am exempt fromthe Contractors License Law for the SPECIAL CIRCNT/MLSC
OZt u9 following reason.(Section 70315,Business and Professions Code:Any city or TEMP MET
METER OR POLE INST.
KZ�� countywhkh requlresa permittoco.tmct,aller,lmprove,demolbh,orrepair
any structure prior to its Issuance,also requires the applicant for such permit to POWER DEVICES
UBie a signed statement that he Is licensed pursuant to the provisions of the
Contractors License Law(Cha(Chapter 9(commencin with Section 7000 of Diel.
3 c M 8 ) SWIMMING POOL ELECIRl�
O slon3.tufts Business and Professi.ns Code)orlhat heisexem therefroand VALUATION
4 5 the basis for the alleged exemption. Any violation of Section m7031.5 by any OUTLETSSWITC XTURES
EEE
applicant fora permit subjects the applicant to a civil penaltyofnct morethan
a o five hundred delta.($500). NEWRESIDEMTAL L TR SQFI. S[OR]ES TYPE CONSTRUCTION
7 6
F-1 1,as owner of the property,or my employees with wages as their sok
compensation,will do the work and the structure b not intended or offered for
$ O
.Is(Sec 7044,Business and Prof.]..Code:The Contaet.e.License law
�$$ does not apply to an owner of property who builds orimprwathereoR and OCC.GROUP RES.UNITS
who doessuch work himself orth mugh hisown employees,provided that such
improvemnls arc not Intended oroffered forsale.IL however thebullding or OTAL:
improvement is sold with in one yearofe.mpletioe,the owner-builderwill have .
Ike harden of proving that hedia notbuild or improve for purpose ofsals.). Cry. PLUMAIEXMIT FEE - FIADDZON'E APN
H L as owner of the property,am exclusively contracting with Iiconsed PFRht ]SSU
contractors to co.teact the project(Sec.7W4,Business and Professions Code:
The Contactor',License Law does not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such pWpors with a �•�- VENT- ATER
cottjactor(s)licensed pursuant to the Contractor's License Law. BAIX OTECT. CE FEE SUMMARY
LI f am exempt under Sec B k P C for this reasonBACI(
M OUTSI DE FEES
DRAINS- RROOF, SANITARY Y N_
• Owner Date RF)rEI Na
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL N
TAX Y
01 herebya(firm a certificate
that I have a artlRate of consent to se141nwre,ora RECEIPT M
certificate ofWorkS F.A.eri Compensation Insurance or a certified copy thereof(Sec. GASYSTEM-1 INC40 EE ETS PARK FY N
3800,lab C.) S RECEIPT
I'M
P.11,y p GAEA.SYSTEM-OVER 4(EA
Cam any BUILDINGVISION FEE
Certified copy b hereby famished. GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
.J esr ified copy b filed with the city inspection division.
J� CERTIFICATE OF EXEMPTION FROM WORKERS' CRFASE'IRAP PAID
COMPENSATION INSURANCE SEWER-SAMTMY-STORM E.A.200FT. Dale Remi [#
(Thissection need out h completed tithe permit lefor o.hundred dollars
($100)orless3 WATER HEATFIt W/VENT/ELECTR ENERGY FEE Y_ N_ ._
I mrtify that in the performanm of the work forwhlch this penNt b bs rd,
1 shag not employ any person In any manner so as to become.bjcit to the WATER SYSTEM/TREATING
workers'Compensmlonlaws of CaBfomia.Date Z. O PAID
O Z Applicant NEW RESIDENTIAL PLMS. SQ.FT. Date Reeei t#
Z 0 NOTICETO APPLICANT.If,after nuking this Certificate of Exemption,you
should become subject to the Workn%compe.ation provbio.of me Labor TOTAL:
N Code,you must forthwith comply with such provisions or this permit shall be BUILDING
deeed revoked.
IL 25> mCONSTRUCTION LENDING AGENCY - SEISMIC FEE
[l Iherebyaffirthat there b a construction lending agency for the perform- / ELECTRIC FEE
Z ante ofthew.rkfm W
or which this permit ie issued(Ser.3097,Ci,C.) TOTAL: ,00
U O Lenders Name PLUMBING FEE . OI
Le.ders Adareea QTY. MECHANICAL PERMIT FEE
LL UImrtifythalhavemaathisapp8ationandamlethattheaboveinformatlon MECHANICAL FEE
O W iscorrea,I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
7. IL relating to building construction,and hereby authoram representatives of this
F N city to enter upon the above-mentioned property for inspection purposea. ALTERORADDTOMECH.
Z Date Receipt#
(We)agree t.save,Indemnity and keep harmiess the City y Cupertino
V against liabilities,jidgmenb,costs expenses whish may In anyway accrue AIR HANULINC UNIT f['O tO,fpO CFM) SUBTOTAL: f)0
againstsald Cdyin nceofthegr nti his permit.
S--NAD AIR HANDLING UNIT(OVER I0000CFM) CONSTRUCTION TAX
ox gna of App sem/ on rector Date EXHAUSTHOOD(W/DUCT CONSTRUCTION TAX PAID:
HAZARDOUS MATERIAL DISCLOSURE
re applicant orfunim budding occupant store or handle hazardous HEATING UNIT(TO IOD,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I ealth and Safely Code Section 25532(x)? HEATING UNIT(OVER 100,000 BTU) TOTAL: Q
❑ Yes M No
Willthe applicant or futurebuilding occupant use equipment ordevices VENTILATION FAN(SINGLE REBID) ISSkl,�f$I� ATE
which emit harardous air contaminants as defined by the Bay Area Air • A�
Quality Management District? BOILER-COMP(3IIPOR 100,000 BTU) _
4Ye [�No
havereadtheh vousmaterials requireernbunderChaper6.95of BODER-COMP(OVER 100,000 BTU) f_�V
the California Health&Safety Code,Sectio.25505,25533 and 25534. 1
understand that if the building does net currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT.
msporoflidity to notify the occupant of the requirements which must be met CRY 0} CunertBIo
prior to issuance of a Certificate of O« paocy.
�\ I
Owner.,auth.rieed agent Date TOTAL: ISSUED BY D UC
OFFICE COPY