20907 APPLICANT TO FILL IN INFORMATION RED LINES --USE BALL POINT PEN'ONLY
Building Protect Identification .- • - PERMIT NO..'
Build mg Add reas..,x•. . . 2090T
�wnerelvame: )one. CITY OF CUPERTINO-BUILDING DIVISION Au LieAliyry>uBMUTAL UAte.
.. �rl
c�(r�dor'anrame: Lrc.No: ,APPLICATION / PERMIT a
X352-d 1{2 BUILDINGELECTRICAUPLUMBINGMF HANICAL - CATEGORY, CONTROL#
,• Architect/Engineer•_ N.
ELECTRIC
QTY, Lie.N - -
PERMIT FEE ' BUILDING PERMIT INFO.
I, ' ' '
Address: ., PFRNBTISSUANCE I-Lao '
LICENSED CONTRACTOR'S DECLARATION F
I hereby affimnthat l am licensed under provisions of Chapter 9(commenc-I"b APPIIANCES-RESIDENTIAL �� JOB DESCRIPTION
Ingwlth Secaon7000)of DiAsion3ofthe Businemand PmfessionsC e,andmy
hrenmla In fullfo���ccc and effect. PANELS - -
License la� Conti 3S2GIfZ �+ 1\
Dale
Contractor' y,�C M eVlff Im TO�,Op AMPS I
ARCHITEC's DECLARATION a, 201-1000 AMPS ' -
�Z Iunderstand my plamshall be used as public records. OVER1000AMPS SQ.FT:FLOOR AREA S/SQ.IT.
µp O
k ([j Licensed Professional SIGNS ELECTRICAL Lb fn¢' OWNER-BUILDER DECLARATION` LIZ SPECIALCI2CUIT/MISC, CJSIx f/'�Y•\ 'fI!L.y6./g
L, I hereby affirm that am exempt from the Conliactor's License Law form•• -
q followingreason.(Setllon 70315,Business and Professions Code:Any city or TEMP,METER OR POLE INST. �,j P E R
cauntywhich requires a permit tommtruct,alter,Improve,derrnldh,orrepal RR{{
q a anyetmclure Inform Its iswance,alsorequmaitheapplicanlfor such permiHO POWER DEVICES ` /1 {^•
EE rG F V Gla a signed statement that he is Ilrensed.purauant to the pmvlslom of th- DATE
C - • 12
ffyy 'Contractor's License faw(Cha(Chapter with Section 7000)of Divl- ON 1
a R SWIMMING POOL ELECTRIC -
O the basis for the alleged Proapti.n. Any violation (exempt therefrom any
�?G
the band(or the alleged exemption. Any vlolatlon of SeRlon 7611.5 by any A S OUTLETSSWITCHFSFIXTURFS 6150 ,- 7" I f 000—
O
applicant fora permit scab)ectstheappllcanttoarnll pemlty of not nnre than 1 O
five hundred dollars(5500).
, NEW RESIDENTIAL ELECTR SQ pL 'STORIES a TYPE CONSTRIICIION
�n ❑1,as owner of the property,or my employees with wages as there d scfl�
for
'
compensation,Business workdeand the s CodvrednoHntended or offered for
p doe(Sec 7044,to Business and Prole elore Code:TM Contracture Llceme Lau
$ doss not apply roan icusi ofproperty who ne., orlmprovo thereon,and
who does such workMmself ort hrough hiaownemployeea,provided thatwch oCC,GROIJIa RF2:I1N1'TS
Improvements are not intended orofferedforeale.If,however,thebullding or - TOTAL: \ '
rmprovementtseoidwithinoneyearofcompldiorytheowner-bullderwillt '111 .
ti urden ofprovingthat he did net build orimprove forpurposeo(sale:). QTy, " PLUMBING PERMIT FEE ',; .FIAOD ZOM? APN
u I,as owner of the property,am exclusively contracting with Iicenan pgRMIT ISSUANCE 1^
rontracrore to c umm ct the prolect(Sec,7014 Bualneaa and Professions Code: I 4(]E)
The Contractor's License Law does net apply to an owner of property who - (EA) I '
- wilds or Improves thereon, and'who commurs for such pSO)ed ALTER-DRAIN&VENT WATER
a with a 2, .'',FEE SUMMARY
,,➢t�actor(a)licensed pursuant to the Contracture License Law. - ..
LJ[
am exempt under Sec. B&P C for thdreemon L BACK FLOW PROTECT.DEVICE 'Z a�' - OuTSIHF i4:ES_ I
Owm Date DRAINS FLOOR RODE,AREA,CONE); SAMTARY Y_ N_
. RECEIPT#
❑ W ORKMANI haw a cSATION DECLARATION 'r f, pp(TURES-PER.TRAP I SCHOOLTAX Y N
• I here affirm that I have a certificate of consent to eel(-Insure,or a �I Oc Q� 1,' RECEIT T#_—
MOWLab C Workers'Compereadonlmurance oracerti(led copy thereof(Sec. 1 GAS-EA.SYSTEM-1 INCA OUTLETS '�t� PARKFEE Y_ N_i. RECEEPT#
I'ollry p CAS EA.SYBTEM-0VER d(EA) -
' � BUILDING DIVISION FEES I
�Cert]tied copy is hereby furnished. '- GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE -
MCertified copy d filed with the sty irupedion division.
GREASE TRAP -
CERTIFlCATEOFO(EMPTION FROM WORKERS' - 'PAID r p
COMPENSATION INSURANCE SEINER SANITARY STORM EA.200FT. Date Receipt#
(this section need not be completed if the permB d(Drone hundred dollars
($100)orless.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_ "
I caddy that In the performance of the work for which this permit is issued
I shall not employ any person In any manner w as to become wbject to the WATER SYSTEM/TREATING '
workers'Compenmtion Lawso(California.Date PAID `
O Z Applicant - NEWRESIDENTIALPLMB. SQFT. Date Receipt#
Z 'NOTICE TO APPLICANT:If,after nuking this Certificate of Exemption,you
should become subject to the Wrolum'Comperuatlon provisions of the Labor TOTAL: I
Cade,you moat forthwith comply with such provisions arthd permit shall be
� > aeemea revoked, I BUILDING FEE 19*{!,Sill
W CONSTRUCTION LENDING AGENCY I SEISMIC FEE
d Z efthy work this permit mit Is bon lend 097,agency Ciforlhe per(orm� TOTAL: /�Aa ICY ELECTRIC FEE 19170
U anceof the work for which this erMtis issued(Sec.3097,Civ.C.) v 1-{.
Ij O : LenaereName - PLUMBING FEE
LL N LendersAddress (QTY. MECHANICAL PERMIT ' , FEE` (MECHANICAL FEEZ7,a�
U lrenrfyt hatl havemadthdapplicationanddatethattheabove In formation
O Ed is correct.l agree to comply with all'city and county ordinanreeand state law. 'I PERMTTISSUANCE f 21 FEES PAID:
.. }. relating to building coretmellon,and hereby authomie representatives of the -
F N city to enter upon the above-mentiored property for inspection purposes. ALTERORADDTOMECH. - u -
Z (We)agree to save,IndemnByl'an d keep harmiem the City of Cu Fenian Date Receipt#
V against liabilities,fadgmentss,costeand expenses which may In any way accrue AIR HANDLING UNIT(TO 10,006 CFM) - I SUBTOTAL:'
gainst said Cl ro/luenre of the gr clog of tM1b permit
AIR HANDLING
UNIT(OVER I0,000CFM) I CONSTRUCTION TAX
" .�cu CONSTRUCTION TAX PAID:'
•'
against..
�ture of Applicant/Contractor^ bate / EXHAUSTHOOD(W/DUCT) .
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous I BEATING UNIT l00,W0BTU) Lola Date ' Receipt# ' _
mated,]as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safely Cod c,Se1ction 25532(a)7 HEATING UNIT(OVER 100,00)BTU) TOTAL: J ✓`"'•Iµ.
Yes ILA No
Wdlthe applicant or(umre building occupant use equipment ordevices VENTILATION PAN(SINGLERESID) ISSUAN(M-E)ATE
which emit hamnlous air contaminants as defined by the Bay Area Air
Qua hty Management L��at "? BOILER-COMPGHPOR100,00p BTU) - UG (�
4 Ym IIQNo v U ti V ^nJO
have read the M1azarTi uua materials mquirements under Chapter 6.95 of BOILER-COMP(OVIR100,0M BTU) IJ
the California Health&Safety Code,Sedrotis 25505,25533 and 25534. I 1
understand that lithe building does not currently have a tenant,that It is my NEWRESIDENTIALMECH. SQ.FT. t + C(rI (?f
r
resporelblhtyto notify the occupant ofthe requirements which most be not Ursis fRll
pnort uance ofaCertificete of Occupancy.
( ,
Owner or authorlaed agent to -
O ISSUED By
TTAL. 2�,
OFFICE COPY ' ' '
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