21961 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address:
to op TA37AU Ave, ��TI 21961
rur0 ams: Mons, --AT1TrCATT0R3UM=DATE
10OKIL- ISG• CITY OF CUPERTINO-BUILDING DIVISION ✓ -
Contraaor'sName: Lk.No APPLICATION /PERMIT
BUTDINGELEC'IRICALPLIIMBINGMFLHANK'Jd, CATEGORY
Ard, ct/Englnaer. �O Na
ZI IPOW C—z? Lie ya`^'f09 QtY ELECTRIC PERMIT FEE BUILDING PERMIT INF
Add.46723 GlaM� S B8)%14, IIC'aaPERM[TISSUANCE 6 EJ F-1 ❑
LICENSED CONTRACTORS DECLARATION ill
I hereby affbm that l am Kemsed under provblau of Chapter 9(mmmenc APPLANCESRESIDENMLJOB DV'RIFTION
IngwithSection7000)of Divleton3oftheB"Yn dPmfomiCodgend '
If..b In full force and effect. PANELS
License Class If
Date Contractor
ARCHITECTS DECLARATION 1201-1000 AMPS
NZ Tundernand my planashall be used as public record, OVERIWOAMPS _ 9Q. .FL AAFA 5/SQ.FT.
F. 9GNSELECTRICAL t c A
M`uS
Licensed Professional oftA 1 tl
OWNER-BUILDER DECLARATION
ro 3 IherebyafBmn that l ameaempt from the antrasewri License law for the SPECIALCORCIJTf/AQFC
FZ following mason.Occtlon 70715,Bushes sed Prafcebne Cod`.My city or uu TE R
O MAP.METER OR POLE INSI.
ColintywhkhrequbnapemW mna d,alter,Improve,de Wh,orrepdr
AIe
anys =mprkxtaift uame,aborequtr theappha tfw.uchpemdtto POWER DEVICES ( /
U file•signed statement that he b licensed pursuantm
to the pds sloof the .-
O Contractor's lkese law(C apter9(commencing with Section 701.,of Dtvl- SWIMMING TOOL ELECTRIC ALllAT1ON
3� sbn3oftheBuWn.endPm eloNCode)orthahebesempthertfmmad
the W.1i for the alleged..roplbn. Any violation of Section 7QH5 by any OUILEfTaST4'DCHES}T%7URPS
applicant fora permit subjects theapplicanl to a civil penalty of not more than nt
Bv�.himdreddollue($M. NEW RESIDENTIAL ELFL'fR_SEF['. RIfS 'IYI'E CONSTRI1CIlOt.'
z "I as owner of the property,or my empbn yewith wages as their sole
C � compersation,wdi do the work and thestructure is not Intended or offeredfor
0 sale Oee 70K Busbnus and Pec(esbna Code:The Cordnctors License law
$$ does not apply to an owner of property who builds or imprwrs thermn,and OCGGROUP RES.UNITS
who don m
such work himself or through his eplcyxes,prided that such
.� Improvements are one intended orcffered forsle.It hwveser,the bulldingor TOTAL
improvement bsdd wnhlnomyearefcmnpletbn,thewvner builderwgI love -
t reien of proving that he did not build or Improve for purpose of Bale.). QTY. PLUMBING PERMIT FEE FTDOD ZONE APN
jL as owner of the property,am a rhedwly contracting with licensed PERMIT155UANCE
contractors to construct the project(Sec 7041,Bushes and Psfesabru Cods:
The Contractor's License law don not apply to an owner of property who ALTER-DRAIN kVENT-WATER(FA)
builds or Improv thereon,and who contracts fee such projects with e
c9alreemrw licensed pursuant to the Contractors License Law. BACK FLAW PROTECT.DEVICEFEE SUMMARY
mec
U I am exempt under SB&P C for this recon
OUTSIDE FEES
Owner - Dee DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
RECEIPT s
WORKMAN COMPENSATION DECLARATION FI)ITURESPER TRAP SCHOOL TAX Y_ N_
❑I heathbyy affirm that I have a cetl0ate of consent to self-Inert,or
RmEpp a
cedlflatetWorkeri CompesationlnaurenmoamrtBfed copy thereof Oec. GAS EA.SYSTEM-1 INC10UTLELS PARK FEE Y N
Policy IfRECEB'f�
Co y—
GAS FA.SY51EM-OVER1(EA) BUILDING DIVISION FEES
dified ropy b hereby furnished. CREASE/INDIISIAI,WASTE QVIIIICE'IDR PLANCHECK FEE
anti=ropyb(Bed with the 1y Ispetion division.
CERTIFICATE OF IXFMPTION FROM WORKERS' CREASE TRM PAID JJ�� S
COMPENSATION INSURANCE SEWELSAMf'ARY-STORM F.A.yTOI;I. Date Remi N '9 `6
(I'hlssetbn need not be completed If the permit Isfor one hundred dollar
I.
($10D)or lm.) WATER FIFATERw/vFxr/E.ECIR ENERGY FEE Y N
I mtlfythat in the pcc
edounce.f the wormb b
k`.,which thio perit aued,
1%Full not employ any person In any manner n a to heecrrs,subject to the WATER SYSTEMfT IFA.DNG
If Woracs'Compensation laws of Gllfmnla.Date PAID
O Z APPBant NEW RESIDENTIAL PLMB. SQFT. Date RIxei tic
Z O NOTICE IO APPLICANT:ILafter maldog this Certificate of Exemption,you
should become subject to the Workeri ampesrtbn provision fthe Tabor TOTAL:
LA Code,you must forthwith comply with such prudsbN or this permit shall be N .O
W > deemed revoked.
1 CONSTRUCTION LENDING AGENCY SEISMIC FEE RE 10
Ihemby a(Brmthat there b a costrutlon lerding agency for the perform TOTAL ELECTRIC FEE
Z aneeofthe work forwh"this permit b bwed(Sm 3097,CIv.C.)
02 LerldersNsme PLUMBING FEE
LL F- Lender,Address QTY.I MECHANICAL PERMIT FEE MECHANICAL FEE
OW I crAifythat l have read thbappllatbnard statethatthe shows Information
IL bconect.Iagreelocomply withaBcltyandcountyordbuncesendnatelaws PERMIT ISSUANCE FEES PAID:
>_ N relaling to bulldleg mnstrutlm,and hereby authodae representatives of this
city to enter upon the abo romtloNd property for Inspection purpose. ALTERORADDTOMECH.
Z (We)agree to svq IMemntfy an d keep harmles the City of apertiou Date Re el ted
V
against WbWties,judgments,cons and expenses which may In any way accrue AIR HANDLING UNIT(70 10,((0 CFM) SUBTOTAL:
ago Cny .usqueroe oft gram goftwpemJc AIR HANDLING UNTT(OVER 10,000CFM) CONSTRUCTION TAX
I v6AKCONSTRUCTION TAX PAID:
Signature Appilant/Contntor Date EXI IAl15'I tI00D M'/DI1CT)
HATARDOUSMARIALSDISCLOSURE
Will the appllant or future build occupant nom or hanldk hararei HEATING UNIT(TO 1(D,(100 RFU)
Date Recti t#
He.hhmaterial a defined by odthe Cupertino 2(47Municipal Code,Chapter 9.17,and the
1Nann and s.rety cone setmn zss37wt Hurwc UNIT(OVER Iro,BBO B'I'N TOTAL: lie. t 0
qYn M No
01the.pplhN o(utum bullding occupant use equlprrcN adevim VENTILATION FAN(SBv'GLE RF9D) IV96W DATE
which emit ha rdousair mnbminantsn deflred by the Bay Area Air
Qm yManagement IXtr+ No
BOBER-COMP 01T OR 1
(. I—I YnNo BOR,ERCVMP(OVEt l(D.000 BTU)
lore
ve ad theF mnb
crus erlab requimmenunder Claimer 6.95 of
the GWonb Hearth&Safety Code,Sett.N 25506,75533 and 75534. I
understand that lfthebu Bdingdoes not mmently love a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT �k,
responsibility to notify the occupant o(the requirements which must be met f &WHO
;c prior to Issuance to CertlRoto of Occupancy. ^
Owner or authorlud agent Date 15SUEDBY:�r
- TOTAL: L
OFFICE COPY
.I