20451 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project identification PERMIT NO.
Building Address:
K 20451
oc a one: A A ,
arse �/s.�l't $ y13�'9Ga Ga�L CITY OF CUPERTINO-BUILDING DIVISION
Comranors Name: Lie.N.: APPLICATION / PERMIT
BUILDINGELECTRICAT PLUMBING-MECHANICAL CATFCARY CONTROL
Its En nee .k is�
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address - js 1 PERhIITISSUANCE ^t t��-4
LICENSED CONTRACTOR'S ECIA ATI N Ip�pt�V y�
Iberchyaffirmthat l am licensed under pmvidons of Chapter9(commene- APPLIANCES-RESIDENTIAL px�d JOB DFSCRII'HON
inenseI Infonforc)adeffelon3o(theBusinessand Prolesslom Code,and my a� s��l
license Iain fuB form and effect. PANELS
License Class LICK
Data Contractor UP 10 2DDAHZ5 ozz�{n
ARCHITECI'S DECLARATION 701-1000"PfI
X
0 Z I understand my plans shall be used as public records OVER Ip00 AMPS SQ.FT,FLOOR AREA $/SQ.FT.
<��° 02;5s
Licensed Professional SIGNS ELECTRICAL N6v.9 15°1
OWNER-BUILDER DECLARATION
SI'CCIALCIItCUIT/MISC
y� owingrsson.(batlamexempfromtheCanmiless nsCodxlawforthe (2 {f,p�' 2�1 ��—
p following Penson.(Section 7p31S,Business and Pm pm ns Code:Any city lr
O I_Y1 TEMP.MEITR OR POLE INST,
county cture rcquircaa hatuanrommtrvciiresth a pmvgdennLLsh,or repair
anyatrvdure pdortolts laeuance,also rcqulrcatheappllmntfor such permit o POWER DEVICES
C a O file a signed statement that he Is licensed pursuant to the provislom of the
Contractors License Law(Chapter 9(commencing with Section 9000)of Divi- SWIMMING POOL ELECTRIC
O slon3of rhe Ousinmsand ProfeniomCode)orthat hebexem chercfmmand Er �
U ON
g Q 5 the basis for the alleged exemption. Any violation of Sections 7FOIS by any (j0.OUTLETSSWITCHESHXTURES applicanrfor a permit subjects the applicant to a civil penalty of not rmore than
five hundred dollars($SOB).
❑1 as owner of the r e NEW RESIDENTIAL ELECTR SQ.FT. STORM. TYPECONSIRUCTION
, e op Pty,or rk and he employees with wagm as thele solemm(See,tion,Buldessand ProfesionsCdurehe Contot actornded o icenseLaw vie bee appy to alnow andf property Code:The Conopoxwewho s Llceme Lawdocs notapply torn owner of through his onemporimprovvidedtatsuchOCC.GROUT' RES.UNITS
impmeementsa orkMmself or ed oroffered
hisownemployees,provided that suchimprovements. ld in(endneyearfcomorsale.tLh nvcgilder ilingor TOTAL:
Improvement braidwithin he did or build
ofsehave
tl7„�uraenwner ofgterhedidna excl orimpmvefwpng with lcense QTY. PLUMBING PERMIT i•'EB FLOOD ZONE nrN
u 4 as owner of the property,am exclusively Business
and Ing with licensed PERMIT ISSUANCE
The Co ontocomtrvnthe Law
(Sec.appy to nese and of pro ors Code: a
The Cotrader'simproves
esthLicense law dem not apply res an owner I Property who .� ALTER-DRAIN -WATER(EA) a�
Wilds or Imprensa thereon, and who matrons for such ppojeM with a FEE SUMMARY
cgatFa am exempt
under ant Soc.
the Contranori License law. BACKFLOW FEE
LJI em exemµunder Sec. B k P C for this mason
DRAINS- R REI,COND. SANITARY Y_ N /
Q Owner Date RECEp'f=
WORKMAN COMPENSATION DECLARATION PER DO SCHOOL TAX Y_ N
❑I hereby affirm that I have a certificate of consent to self-Inure,or a < RECEB'f N
ceniflcareof Workeri Compemarionl=mnmoramnifiedmpythereof(Sec. GAS EA. -1 WC. PARK FEE Y N
3800,lab CJ
Policy NRECEIPT N
Com any G p(FA) BUILDING DIVISION FEES
[�ce [fed copy bhereby furnished' E/ D 2L WA INTFxcFrTOR PLANCHECKFEE
❑Cenlfied copy b filed with the city impoe lon division. C[���i� �(j�
CERTIFICATE OF EXEMPTION FROM WORKERS' GR PAID5'-r1-�Q SSINS
COMPENSATION INSURANCE S SA .700FI'. Date RCCei 1#
TThissection need not W completed if the permit b for ors hundred dolls t
($IOB)mlcss2 .L� TkR / EL ENERGY FEE Y N
I mrtifylhat In the performance of the work forwhlch this permit is laced,
I shall not employ any person in any manner so as to become subject to theO
Workers Compensation laws of California.Date WA �'�/ PAID�Z�' G SSY68
OZ Applicant NEWR ALP 5Q F[. Date RCCCI 1# �tC�
Z O NOTICETO APPLICANT:]LaRer making this Certlficale of Exemptionyou
should become aubjM to the Workers'Componegion provisions of the Labor TOTAL:
N Code,you must forthwith comply with such provisions or this permit shall be
W > doemed revoked. BUILDING FEEt
CONSTRUCTION LENDING AGENCY SEISMIC FEE a
Ili eof theIhembyaffir
oris Ihat them bammtrvcilon lending agency for the perform DIAL: ' ,,rayt�e ELECTRIC FEE tfX7 "-�I
Z once of theworkfor which this permit b tuued(See.3097,Civ.C.) W
U O ]enders Name PLUMBING FEE 00
LL h lender.Address QTY. MECHANICAL MIT FEE MECHANICAL E ZO
O W I mnifythat l have read thbapplicatlonand statethat theabove Information
bmrren.lagreetocomplywithallcityand countyordinances and state laws I PERMIT ISSUANCE �,�,cD FEES PAID: I
- N relating to building construction,and hereleyauthorirc representadvesofthis
F cityto enlerupon the abovenrentlered property for inspection purposes. ALTER OR ADD TO MECH. �^
Z —Date Recei t#
(We)agree to save indemnity and keep harmless the City of Cu pertinoaccrue
V
against liabilities,judgrrcnta,costsand expensm which may Jassy way accrue AIR FIANDLING(INTI(TO 10,00)CIM) SUBTO AL:
against said City In consequenre of the granting a this permit. CONSTRUCTION TAX
AIR HANDLING UNIT(OVER 10,000 CFM) j
Signammof Applicant/Contractor Date EXHAUSTHOODIW/DUCT) CONSTRUCTION TAX AID: '
HADIRDOUS MATERIALS DISCLOSURE
Will the applicant or futurebullding occupant store or handle hazardous HFATING UNIT(TO 100,0110 BTU) Date Rece t#
mated as defined by the Cupertino Municipal Code,Chapter 91Z and the �e�
flealihand SafetyCode Senion25537(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL. q-1T.Ifet'EP k
❑Yes No
Willlhe applicant or suture building occupant useequlpment ordevices Z VENTILATION FAN(SINGLE RESID) �s� ISSUANCE DATE
which emit haeanlom air contaminants as defined by the Bay Area Air
QjjL1Ity Management Dbldci7 BORER-COMP 0FR'GRIIXI,000 BTU)
yes I��II No
have read the havaiJous materials requirements underChapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Iimlth k Safety Code,Sections 25505,75533 and 75530.I
understand that if the building does nes currently have a tenant,that it b my NEW REST DENHAL MECH. SQFT JUiV t
responsibility to notify the ocmpafit of the requirements which must be met 19511
prior to issuance of a Certificate of Occupancy. (f%�
Owner or aulhorlad agent Date 0� ISSUED IfYv-' 1
TOTAL:
OFFICE COPY
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