20704 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project identification ` - PERMITNO.
'x /6B U7ds be qV o 20704
rs ante;
A�41Z 'Axh
one.
�WLY0./ CITYCUPER1IN0.BUILDIN6 DIVISION
I NO co a ti : //�— N APPLICATION /PERMIT
' • C" 7.73 BUILDING-ELECTRICAGPLUMBINGMFCHAMCAL CATEGORY CONTROL If
Architect/Engineer. Lie.No:
I Q � QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
�ya/ a J` PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION .
Thereby�fflrmthat l am licensed under providers ofChapter9(rommen APPLIANCESRESIDEMIAL JOB DESCRIPTION
I\V Ingwith S��fy ,•.�Iy�'elon3eDhe Buslneaeand Pro(eulone Code,and my
lice^�" II r6eRM. 1/ /+ 1 J PANELS
L CW�LIcp 'II V1
D"? 'A UP TO 200 AMPS
CXITECP cls RATION OVER0OXIAM
�2 ]understand my plata ehaB be ueedupub0crerorda "'�� OVER 1000 AMT'S SQ.FT.FLOOR AREA f/SQ.Fi.
O
Z� Licensed Professional SIGNS ELECTRICAL
z" y OWNERex exempt
DECLARATION ® '
su?7 SPFCIALCIRCUIT/MLSC
I hereby afBrmthal lam exem from the Contractor's Licenss Gwlor the
following mount.(Section 7m1.5,Business and Professions Code:My city or p p
s:� TENP.MEfQR OR POLE INST. B p E R
county which requlresa permiltoronstruct,alter,improve,demolLsh,errepair 'v
4 < anyrtructure priarto its Issuance,alanrequires theapplicant forsuch permit to POWER DEVICES
WF� rJ BE,a signed statement that he tr licensed pursuant to the provisions of the
Q3 v.J, ContnRore License Law(Chapter 9(commencing with Section 7000)of DWI. SWIMMING POOL ELECTRIC VALUATION
0I sWn3oftheBuslneuandProfesslonsCode)erthathebexemptiherefromand
Gthe basis for the alleged exemption. My violation of Sedlen 70315 by any OUTLETS—SWITCHES-FIXTURES DATE
hy5 appBcant fora permit subjectsthe applicaotto a civil penalty of not more than
E� BF T,as
dner ars of
epro NEW RESIDENTIAL ELECTR SQ,FI. STORIES TYPECONSTRLYTION
FIT,as owner of the property,or my employees is
with wages r thele woe
7 Q
compensation, Code:The
Contror actors
or offered w
t] or
aaoe(Seoapply Boninessner Professions Code:TheCImproves thereon,
law
$ don not apply to ak owner of property who n builds or improves thereory and OCC.GROUP. RIS UNITS
who
ovem ntswork t intenlf ded
orough hlaee s employees,provided that such
Improvement are not Intended proffered(mule.I(howeven the building or TOTAL:
Improvement twWwithin omycarofcompldbrytMowner-bulWerwBl have
tlntVenofproving that he did not bund or improve for purpose ofaale.). QTY. PLUMBING PERMIT FEE
u T,as owner of the property,am exclusively contracting with licensed FLOOD ZONE AI'N
contactor to construct the project(Ser.706ly Business and Professions Code: PERMIT ISSUANCE
The Contractor's Luras law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) LIR/
build.or'Improvss thrones,and who contracts d
for such Inp ee with a FEE SUMMARY
c�(a.dor(a)licensed pursuant to the Commerce,License Law. BACK FLOW PROTECT.DEVICE
LJI am exempt under Sec. B&P C for this reason
DRAINS FLOOR• ROOF,AREA,COND. SANITARY Y N Owner RECEIVE
KM
WORAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N
❑[hereby affirm that I have•certi(kate of conssnt to elf-Inure,or RECEIPT M
certificate of Workers Cempereatloelnsu em ora certified copy thereof pec. GAS EA.SYSTEM-1 WCAOUTLEES PARK FEE Y N
3900,Lab C.I RECEIPT a
Policy M GAS EA.SYSTEM-OVER 4(FA)Com any BUILDING DIVISION FEES
ErCertlled copy It hereby furnished. GREASE/INDUSTRI.WASTE INTERCEPTOR PLANCHE•CKFEE
Certified copy is filed with the city Inspection division.
CERTIFICATE OF EXEM PTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE / SEWER-SANITARY-STORM EA 2TOPT '7�� Date RCtt'1 [�(
D'hlssedlen need not be completed If the permit is!carom hundred dollars C
p10B)or lana.) WATER fIEATFIt W/VENT/E.FCTR ENERGY FEE Y N_
I certifym
that In the perforrncenf the work for which this permit I.Isaued,
I shall not employ any person In any manner w as to become subject to the WATER SYSTEM/TREATING PAID
Workers'Campensatlon Laws of Gllfornt.Date
0Z Applicant you NEW RESIDENTIAL PLMB. SQFT. Date Remi till
Z 0 NOTICETOesti.bCAI.the after rs Comakinpe Certificate icons oftof le Lata
W C d,y...,tf fthditthe Workers'Compens l... thionsolthe Leber TOTAL:
Code,you must forthwllh comply with each provtlons orlht permit shall be
W 9 deemed revoked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
IL I hereby alBrrn that there its a construction lending agency for the perform- ELECTRIC FEE
=1Z ante ofRhe work for which this permit is,Issued(Sec.3097,Civ.C.) TOTAL:
U0 I.nder'.Name PLUMBING FEE
IL I— Lender'.Addrcn QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Irettilythatl have madthtappllcalionand statethatthe abovelnformatlm
IL Is rorted.I agreeto complywilh all city and county ordinances and state laws PERMIT ISSUANCE FEESPAID:
>. W relating to building construction,and hereby authorize representtivea of this
Z dtyto enter upon the abowre entioned property for Inspection purposes. ALTERORADDTOMECH. Date Reel tM
(We to ave,tdcrtWty and hr u the Clty of Cupertlm
V .gal Bab les,jrdgmenb,coateand hl the CkLy wayamue AIR IiANDLINC IIMT(TO 10,000 CFM) SUBTOTAL:
ag t I ity in ronsequeo a the s t n thl rouL
AIRHANDLING UNIT(OVER IO,OOBCFM) CONSTRUCTION TAX
Slgmtu o App t/Contractor Date IXHAUSTHOOD(W/DWT) CONSTRUCTION TAX PAID:
ZARDOUS MATERIALS DISCLOSURE
Will the applicant or futurebullding occupsetstere orhandle hazardous HEATING UMTOO 100,000 BTU) Date RCCCI t#
1 I
materialas defined bythe Cupertino Municipal Cods Chapler9.IZ and the
Healthand Sally Code�zz--S�eton 75531141 HEATING UNIT 100,000 BTU) TOTAL: s[x�• ('
�Yss LJNo VENTILATION FAN RESID)
Will Y the appilont orTTuutNo building occupant use equipment or devices I$$ ATE
which scot hazardous air cumamimnt as deRm:d by the Bay Area Air
Quality Management District?1No BOILER-COMP pIE'DR100,IXq BTU) JUL7 O Inn0
Ye.
No U!/L i JJ
havereadte.1th&Safety
materials Section. mentsun33 and 25534.
of BORER-COMP(OVER IW,000 BTU) -
theerstftmela aedtat If
Clods,Sections?5505,ve a tenant,
-
undentandthatlf Rhe building dote not correctly havealenanL that lt0my NEW RESIDENTIAL MECH. SQ.FT, f�'J�dlm'd1'a//nr�aw
ibllllylondifytheotaccupant olthe ulrcmenhichmmmyyystbemet
' rt issuance of3Ia��Certif tnoofQ�+�anry.
Ownerer au zed agent Date ISSUEDBY: �^"�V3 �`ay
TOTAL:
OFFICE COPY