20112 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification - PERMIT NO.
BuRairg�/sa0-7/ �, _ _ - 20112
oars one: - A A A
:57C�`.�,�-, 4" ham? 1s a
CITY OFCUPERTINO-BUILDING DIVISION
• , Contractor's Name: .a.- Lk.�1o: APPLICATION / PERMIT �"q8.
BUILDINGELECTRICALPLIMBING-MECHANICAL CATEGORY CONTROL M
Architect/Engineer. Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT;INFO
Address: 27Y'— /YLG�v LJ�.'.^- /3��aY1 PFRMITISSUANCE ❑ 11 ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of ChaPlerg(commeneAPPLIANCES-RESIDENTIAL
JOB DESCRI'fION
It... .1.io Ian,ea7000)odaffect. ofthe Business and Pro(essionaCode,and my
license is In full r rte and dreg. ��..{{�{(`k PANELS
License_Ctgas 4, , Contractor
i ` A G�11•J A\�` I 1`( n-(
Date r_—Contractor
t ARCHITECTS DECLARATION 201-1000 AMPS
OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
0Z Iundersland my playshaRW used as pubecrecwds.
OSIGNS ELECTRICAL
m Z w Licensed Professional
GQ OWNER-BUILDER DECLARATION -SPECIALCEtCU1T/MLSC
ZH Z Iharebyaffirmthallamexemptfromthe Contractor's License Lawforthe -
pO following reason.(Section 70115,Business and Professions Code:Any city or
TEMP.METER OR POLE INST.
q5 county which requbesa permit to construct,alter,improve,demolish,cumpalr
Cal anystructure priortoits Issuance,alsoreiuirestheappllcant for such permit to EWER DEVICES
file a signed statement that he Is licensed pursuant to the provisions or the
7p5 O w i- Contractor's License law(Chapter 9(commencing with Section 7000)of Divl-
�,�0 sion3ofthe Business and Prefessians Code)orthat he le exempt there(romared SWIMMING POOL ELECTRIC VALUATION
�.' the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESHXTURES
spplicenl fora permit subjectsthe applicant to a civil penalty of not more than
o five hundred dollars($500).
.n,c
..�n ❑I,as owner of the property,or my employees with wages as their sok NEW RESIDENTIAL ELECTR STORIES TYPECONSTRUCTION
k7.< compensation,will do the work,and the structure Is not intended or offered for
5 O sale(Sec.7044,Buaimaxand Pretensions Code:The Contractors License Law
� $ does not apply to an owner of property who Wilds or improvea thereon,and - OCC.CROUP RES.UNTfS
who does such work himself.,through his own employees,provided that such
improvements arc not intended oroffered forsale.If,however,thebuildingor TOTAL:
Improvement lsseld withlnoneyearofcompinion,theowner-W BderwBlhave
t"rden or proving that he did nor,Wild or Improve for purpose of sale.). QTY, L G FEE hTppD ZONE APN
I,as owner of the property,am exclusively contracting with Ilmosed PERMIT A E
contraction to construct the project(Sec.7044,Business and Professions Code:
The Contractor's License law dons not apply to aet owner of property who ALTER-D TER -
Wilds or Improves thereon,and who contra for such projects with a FEE SUMMARY.
tI actor(s)licensed pursuant to the Contractor's License Law. BACK PROT T EVI
u l am exempt under Sec. B &P C for this reason -
DRAIN RRCOF,AREA, SANITARY Y_ N_
Purser Date RECEIPT 0
ray WORKMAN COMPENSATION DECLARATION� I.IX.Na SCI100L TAX Y_ N_hereby affirm Mat I have a certificate of consent to self-Insure,or RECEBrf X
3800,Lab CJ
c rtiflcamof Workers'Corepor ationlnsuranmoracartifedcapytherrof(Sec. GAS.EA.SYSTEM-1 INC.40ITILETS PARK F� Y N
- - Policy L -7 5"a3 RECEIRTN
t cam n4,
GAS EA,SYSTFTI-OVER 4(FA) BUILDING DIVISION FEE
®Certified ropy is filed with the city
Inspection division S
[Certified copy u here tumGREASE/INDUI L WASTE INTERCEPTOR PLANCHECIC FEE
ity ,
CERTIFICATBOFUEMPTiON FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANRARY-STORM EA.](IOF I'.
(rMsseetion need not be completed If the permit Is forone hundred dollars Date5ate RCCEi t#
(9100 caless.) WATER HEATER W/VEvu'r/ELEcrR ENERGY FEE Y_ N_
1 cartify that In the performance of the work!.,which this permit Is Issued,
I shall not employ any person in any manner se,as to become subject to the WATER SYSTEM/TREATING Worken'Compensstionlaws of California.Date PAID
0Z Applicant NEW RESIDENTIAL I'LMB. SQFT. Date R 1 #
Z U NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become,subject to the Workers'Compensation provisions of the Labor T
CCW Code,you=at forthwith comply with such provisions orthb permit shall be BUILDING
W 7 deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FB
Il Thereby affirm that there k a construction leadingagency forthe perform TOTAL: ELECTRICAj II
0 ZO, LaMarche work!.,whkhth6 permit is Issued(Sec.3097,CIv.CJ
U _ ,.code,§Name PLUMB4012E
U. F Landar's Add. QTY. MECHANICAL PERMIT FEE MECHA L E
U lcertifythatl havemad thleapplicationand state that the above information
- 0W Iscorrect.l agree to comply with all cityand countyonlinancesand statelaws PERMII ISSUANCE FEESID
M relating to building construction,and hereby authorize representatives ofthb
N city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
z (We)agree to save,indemnify an d keep harmless the City of Cupertino Receipt#
U against liabilities,judgments,costs and expenses which may In any way accrue AIR HANDLING UNIT(DO 10,0ID CFM) SUBTOTAL:
against said City in consequence of the granting of this permit.
At R HA NDLING UNTT(OVER 1 Q000 CIM) C T CTION TAX
Signature of Applicant/Cantron.,. Data EXHAUST HOOD(W/DUCT) CON RUCTION TAXPAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a pplkant or future building occupant store or hand lc hazardous HEATING UNIT(TO 100,060 BTU) Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the
Health and Safety Code Section 25837(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
E] Yea Ir N.
Will the apple.nt.,future building cam pant use equipment or devices VENTILATION FAN(SINGLE RF_SID) ISSUANCE DATE .
• which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management Distrint BOILER-COMP QHROR 100,000 BTU)
4Ya, ��No
haveread the h dousmaterialsrequirementsunderChapter6.95of BOILER-COMP(OVER]W,IXp BTU)
the Ca tang t Health&Safety Code,Sections i ru ntly have a t...d 25534.1
understand that if Health
building noes Se ti,randy have 33 ands,that it is my NEW RESIDENTIAL METH. SQ.R.
responsibildyto notify the occupant of the requirerrcntswhich the met
prior sssuanca ofa Certificate of ����yi--s. r
Owner or �d agent �/��' ISSUED BY:�-'x-/�
TOTAL:
OFFICE COPY