20853 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Psi ect Identification - - PERMIT NO, -
Build Ing Add reu: - t f7 O('�I�
C.r7 d .0 Z y G'- I C' G 8�5
wncre came: one: - - p
.CITYOFCUPERTINO-BUILDING DIVISION
cantractar'e Name:, . Lie.No: 'APPLICATION I PERMIT
BURAINGELECTRICALMLTMBING-MECFUMCAL CATEGORY CONTROL M
Architect/Engineer. Llc.No:
' QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE ❑ 11fN ❑
LICENSED EO CONTRACTOR'S DECLARATION Imo'
I hereby afflr70that)Division
funder th.B.provlsloneof Chapter9(commmc APPLIANCESRESIDENTfAL JOB DESCRIPTION
inense Is In fon70re afdefelm3oltheBufinneand ProfesslonaCodeand � 0 y
limns.bin full!orae and effect PANELS v 1
Limnsc Cl.. LiaN '
Date Contractor UP TO 2DO A
ARCHITECTS DECLARATION 201-1000`NAPS
qua re0 ZO I understand my pl ns.hall be used u public records. OVER 100L
0 AMPS SQ.FT.FLOOR AREA $/SQ.F -
E Licensed Professional SIGNSELECTRICAL
«<< La OWNER-BUILDER DECLARATION SPECULCIRCUIT/MLSC
zF IherebyafRmnthatlam semptfmmthe Contractor's Limnselawfmthe
o following reason.(Section 70715,Business and Pmfe.I..a Cade:Ancity or
li FZE' countywhlchrequlreaapermittomrotruct,alter,lmpmve,d,mlbh,ormalr TEMP.MEERORPOLEINST. -
anystructurepriortoits Issuance,also requlmthe applicant for such permit to SWIMMINGPOOPOWER DEVICES
GPOOL ELECTRIC
O file a signed statement that he ls licensed pursuant to the pmA ime,of the
�0ati Contractor's Liceme Law(Chapter 9(commencing with Section 7000)of Divi- ( VALUATION
Aon3 ofthe Business and Profealora Code)orthat he fit exempttherefromand '
O the basis for the alleged exemption. Any Wolation of Section 7031.5 by any mOUTLETSSWITCHESFI%II1RFS- r/�
applicant fora permit subjects the applicant to a civil penalty of not
orethan /
$
five hundred demodollarthepro NEW RESIDENTIAL ELECTR SQrF. STORIES TYPE CONSTRUCTION
�n ❑I,ae owner will
the property,or my employes with wags ea thele sok
compensation,7Mn,lbodnethtted I' finnd ihestmcture a:Tle Ant dructu'o License
d for
Law I
doe(Sec.7044,to alnow andf Property Coca:The or improves hereon Law
$ dos no such torn owner or ofp rough who
nempoyees,pvaied that such
- OCGGROUP RFS.UNITS
who
ovementsa nhimselfedorough his owne.If,howeprovidedihatsuch
improvements lni.nomyearofredfor ea Ntheh ne-bugderwilI g orhave TOTAL: -
Improvemenilssoldwlihlnoray.aro(complctioMthe owner-budderwlll have
I denofpmvingthathedld not build or improve for purpose of age.), QTY. .' PLUMBING PERMIT FEE FLOOD TONE APN
as owner of the property,am exclusively contracting with Bernard PELNIT ISSUANCE
mr on to mstruct the project(Sec.7044 Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wild. or Improves thereon, and who contracts for such p5ojectz with a FEE SUMMARY
cc6ector(s)licensed pursuant to the Comratlor'sLicense Law. BACK FLOW PROTECT.DEVICE
I am exempt under Sea
B A P C for this mason
DRAINS FLOOR,ROOF,AREA,GOND. SANITARY Y N
• Owner Date RECEBRM .
WORKMAN COMPENSATION DECLARATION FD(M(ES-PER TRAP SCHOOL TAX Y_ N
QI hereby affirm that 1 have o ol...e of consent to py tnsure,ora RECEIPT N
mrtiflateo(Worken'Compewtlonlmunns me artlf4d ropy thereof 6ec. GAS EA.SYSTEM-1 INCA OUTLETS PARKFEi Y N
Polic380(fy
Poliq N RECEGAS EA.SYSTEM-OVER 4(EA) DING DF N
Cam any BUILDING DIVISION FEES
E3 CertiBed copy 6 heed with
cit. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHE'CK FEE
�Certlfied copy V find with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP .- PAID
COMPENSATION INSURANCE SEWER.SANITARY STORM EA 20017E Date RCCeI t#
(This vection need not tr completed If the permit ls forcer hundred della.
(E100)ar less) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certify that In the N fornanca of the work forwMch this permit is lssued, —
I shah not employ any person In any manner n s to become subject to the WATER SYSTEM/TREATING
Workeri Compensation Laws of California.Date PAID
O Z Appil.NOTICE NEW RESIDENTIAL PLMB. SQFF. Date Recel t#
Z O NOTICE TO APPLICANT,If, her nuk!ng Certificateis Exemption,you
should become.forth tothe
co Workers'such praalionprovbions of s permit Labbe - TOTAL:
N deemed revoked. BUILDING
comply with such provislamarthlsperMtahall be
W 7 deemed revoked. FEE
CL CONSTRUCTION LENDING AGENCY A-�� SEISMIC FEE
I hereby affirm that there is a construction lending agency for the perform-
ance
erform G ELECTRIC FEE
Z Pane of the work for which this permit b bound&r.3097,Civ.C.) TOTAL:
LL LL 0, I...Lendera Ad mar QTY. MECHANICAL PERMIT - 'pgE PLUMBING PEE
O W I mdifythatl have read thinepplicationandstatelhattheabovelnformatlon "" MECHANICAL FEE
CL Ismurect.I agree to comply with all city and county ordinances and pate lawn PFRMI7ISSUANCE, FEES PAID:
>. relating to building construction,and hereby authomm representatives of this
N -
(— ne
V) city to enter upon the above-mentioned property for inspection purpose.. ALTERORADDTOMECH.
— (We)ogre.to save,led.mnlfy an d keep harml..s the City of Cupertlne Date Receipt#
against liabilities,judgments,caps and expenuv which ma In anyweyaccme AIRFIANDLINGUNITOO10,ODOCFM) SUBTOTAL:
ago Wi rcalod by in convryue cel the olio fthle it.
' AIR HANDLING UN IT 10,000CPM) CONSTRUCTION TAX
s no pplieantttt/ entrants pat. IXFIAl15THOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT DO 100,000 BT[J) Date RCCeI t#
material as dented by the Cupertino Municipal Code,Chapter 9.12,and the —Date
a ion 25532(a)? HEATING UNTT(OVER 100,000 BTU) TOTAL; x
❑ Yes /_
Wiil the appllanlor uture buildingocc�pa.t use equipment or devices VENTILATION FAN(SINGLE RESID) SV 'N�EDATE
which emit havrdousa mntaminantsaade0nedbythe Bay Area Air
.�
Quality Management District? BOILER-COMP UHPOR 100,000 BTU) (� 81990 "
4Ys RUG u
havc read the bazar ossa materials requirement under Chapter 6.95x( ROILE&COMP(OVFR 100,000 BTU) U
the California lislth A fety Code,Sections 25505,25533 and 25534.1
understand that iftheWildingdoe,Wt.rmnByhavratenant,that ltismy, NEW RESIDENTIAL MECN. SQkT. /x'�s
ty nF(j(�Dp l(1(I
mpmuibillty,to notify the occupant of the requirements which=at be met city of G- -- .
prior to lasuanc faudiBca nry.
ser or authorized agent Date
' TOTAL: ISSUED PY:v V
OFFICE COPY