20720 APPWCANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identiifficatti'iio^onr-s . 1 PERMIT NO.
Building Add C ti�.i r<SA INF L}�I�I`+ L Z O7
1 20
nen amc: u one;
AIII�S {t . S�slC I—S!;'XZ 12 CITY OF CUPERTINO BUILDING DIVISION
APPLICATION /PERMIT,
BUILDINGELECTRICAIPLIIMBINGMECHMCAL CAT-OAORY CONTROL N/
I Architect/Engineer. ' LIc.No: I I �9
il
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE (�
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm that l am licensed.nder provbmr.of Chapter9(mmmenc. APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwith Sedlon7OW)of DiAsim3ofthe Bue(nemand Pmfe =sC-oeteand
Iianw is In full force andc. PANELiceLS
Data m Lk0
.Cla
Date Cent.dor UP TO 2DOAMPS 'ZI
ARCHITECTS DECLARATION 9111-1000 AMPS
reOO Iunderstand my plans slut be used as public records. OVERIODOAMPS SQ.FT.FLOOR AREA $/SQ.Ff.
6: Licensed Professional SIGNS ELECTRICAL
d6 'OWNER-BUILDER DECLARATION
G &
Iherebyaffirtm ntlutlaexempt from the Contractor's Llanx Law(.the SPECIALCItCU1T/M[SC
following reason.(Bodies 70)15,Business and Professions Code:Any city or / f j D
Or� TEMP. OLEINSf. VL Vit
any tm mpeorrequtresapermRbaLuregt,elter,Impmvgtforauderoofth,arrepalr /��
any etvdurc statement
L�t he In licensed rersuant to the revisions of t e Ii7WFR DEVICES 1
❑h a signed rtatement that he h licensed pursuant to the provisions of the
O w GContractor's License Law(Chapter 9(commencing with Section 7000)of Dlvl-
i SOS aSWANG POOL ELECTRIC
VALUATION
Q 5 the bash for the alleged exemption. Any violation of Section 7mi.S by any OUTLETSTCHFSFIXTURFS G� e V
applicant for a permit subjectsthe applicant to a dvil penalty of net more'ban o
five hundred dollars(5500)
E]1,as owner of the property,or my employees with wages as their sole NEW RFS] LELEC SQ.FT. STORIES TYPECONSTRUCTION
mmpenwlon,will do the work and the structure Is not intended or offered for
q role(Sec.7004,Busbiem and Pmfeselons Code:The Contractors Lt..Law Y
5$ does not apply to an owner of property who builds or improves thereon,and OCC.CR RFS.IWI'f5
who doeesuchwork himself or through his own employee,provided that such �� I
Improvements are not Intended oroffered for sale.If,however,lhebulldingor TOTAL:
Improvement h wld within omparo(compldioN the owner-bulderwill have
tl(Ltiurdeno(pscvingthrt he did notbuudorlmproveforpurpo°eofsals.). QTY. PL BING PERMIT FEE pP.00 ZONE APN
LJ;as mune,of the property,em exclu derly mntrading with Iicenaed PERM ANCE
contract..to rorntrud the project(Sec.7044,Business and Profemiom Code:
The Contractor's License Law dose net apply to an owner of property who AL DRAW Is VENT-WATER(EN
bullets or Improve thereon, and who mmrad° for Duch p(ojem with a FEE SUMMARY
c�Rt(�ctorWhoensed pureuantto Me Contrador'e Ll.nse Law, FIAWI'ROTECT.D CE
LI I em exempt under See B Is P C for thiotwo
• Owner Da n NS FLOOR ROOF, CONI. SANITARY Y N_
WORKMAN COMPENSATIORECEIT N
N DE RA NpER TRAP SCHOOL TAX Y N
[21 hereby.1firm that I have•.rtl(icate of sent to If-Insure,or a RECEIVE M
artlfiate.fW.rkere'Comperuafi.n Imuran.. aartified. thereo(6ec. GAS EA.SYSTEM-1 WC40111L PARK FEE Y N
Polley N
Poli, C.) RECE?fp
N_
I!Cam ny CAS RA. -0V I BUILDING DIVISION FEES
Certified copy h hereby fumiahed. GREASE/PND srRc srE Fr PLANCHECK FEE
Certi
fied copy I.(Ikd w(th the city Ina ton division.
CERTIFICATE OF EXEMPTION FROM WOR KERS' ERASE TRAP PAID
COMPENSATION IN URANCfi -SANITAR god app Date Re I t#
(fhissedionneedn.tbemmpletedlfthe ermlb(orone hondreddola
(SIDD).alem) WATERTERw vENr/Fd.ECTR ENERGY FEE Y_ N_ /
I artifyfhat In the performance&the for which this permit is Issued, �I
I shall not employ any person in any manse as to become subject to the N
Workers Compensation n Laof California. ATER SYS /TRTING PAID
E4
. Da
0 Z Applicant NEW RD SQFT. Date Recei t#
Z O NOTICE TO APPLICANT:If,after making this CerlBlate of Exemption,you TOTAL: a�3
Fshould become subject to the W.rke.''Comperwtion provisions o(the or
V) Code,you most forthwith comply with such provisions or thin permit shall be BU
W j deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
tL shereby of@fe'rwhbar herehammit 6 tion Issued(Sec. ency
Civ. .) perform- - ELECTRIC FEE
7Z aendersework(orwNchNbpermitis issued(Sec.3097,CIv.CJ TOTAL:
LL O Lenders Name PLUMBING FEE
LL F Lenders Adaren QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W IaMtfy[hdl hivemad lhhapplLtbnand shtyodNeabove lnfomu.we
G haared.lagreeto compuctionalcityandmuntymdlnancesand DeS.I!tws PERMIT ISSUANCE FEES PAID:
} cityraltogtobu pen to abovdlontionedinst reby rtyorinise representatives ofthio
J. N cityWenter
ee to the,Inde-mnifyand propertyforthe Cit purposes. ALTER OR ADD70 MECH.
Z (We)agreer.rove,IndemNty and keep harmlessthe City of Cupertlm Date ReO t#
V agaWHlabliueq Wdgmenre,nM anetexpense - hismay to anyway acme AIR HANDLING UNIT IED 10,010K)CFM) SUBTOTAL:
B.i.t.aid City In mosequen fehe anties uftble It. ,
7� p 6 AIR HANDLINGUMT(OVER 10,0011CFM) CONSTRUCTION TAX
Ignamre of Applicant/Contractor - Da(te EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS Di 105U E
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BM Date Recel t#
mrtetlal as deQQQned by ted Cupertino Municipal Code,Chapter 9.17,and the
HeallhaM Si 5ect1.n95539(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
Rill
�—IY Y. No
Illthe applicant. w.building.avp,.t..equlpment ordevias VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which emit havnlous air Contaminants as defined by the Bay Area Air
lity tDistrict? BOILER{OMP DIV OR I00,0M BTU)
Yes No
alcove mad the nus materialv.qulrements under Chapter6.95 of BOMER-COMP(OVER 100,000 BIT])
the California Health A Safety Code,Sections 95505,75533 and 95534. I
understand that if the building does not currently have a tenant,that it h my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to net lfy the occupant of the requirements which moat be met ,
p to Im�uµn=o(^Certificate of Otlponcyj 6 '
o.
.r or aulh.dzed agent Dat TOTAL: ISSUED BY;
OFFICE COPY