20886 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PFILWT NO.
Building Addrev:
<'1 D 20886 0 8 8 6
. G �j/s�j/( �M/
cors ante: one: A
1Y1CRh ' ZZQi W 2is��35 CITY OF CUPERT[NQBUILDINC DIVISION q _jr�7(?n
Contra",Aayra�N�ame: Lic.Ne: APPLICATION / PERMIT
fJE""a� BUILDING-ELECTRICA PLUMBINGMECHAMCAL CATEGORY 1 l lJ
CONTROLM
Architect/Enginnr. Lle No:
_ QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
BLUG SIM PrUMT 7T .
Address: PO MIT159UANCE ❑' ElLICE.NSEDCONTRACEOR'SDF,CLARATION
IMreby aEl
ffirm that l Am licensed under prwislonsofChapter 9(commenc APPLIANCESRESIDENTIAL JOB DFSCHH-LION
Ingwithslefolforceofcieffeon3o(lheguslnessandlmrofnelomCode,and my ��� �_ - _ ���
Ilcensebinim'70ceand'effect, „ - PANIBSI - f'�1I'G`�
License Cbn Lk.# -
Date Contractor TIP TO 2DOAMPS - -
ARCHITECPSDECLARATION 201-1000 AM75
Po?Ky I understand my plans shall M used n public records. OVER 1000 AMPS OOR AREA F/SQ.Ff.
,..: 19 "Licensed Professional - SICNSELFCTRICAL
O - �/'\/ .
6 N OWNER-BUILDER DECLARATION 0+ 4 �O
{-n• 3 SPECIAL CIRCUIT/MLSC
Pt.., Thereby a(Orm thatlam exempt fromthe Contractor's Umnie law for the
Sol lowing mason.(Section 7031.5,Business and Professions Code:Any city or
countywhkhmqulmsaper tocoru ct,alter,impmvgdemlWh,ormpalr TEMP'ME7ER LR POLE INS(.
g5
anystructure pri°rto Its Issuance,also requireathe Applicant for much permit to
elle a signed statement that M Is licensed pursuant to the provlslom of the —POWER DEVICES
Contractors License Law(Chapter 9(commencin with
SWIMMING POOL ELECTRIC
„ aion3ofthe Buainessand Pm(esslaru Code)arthat helsexempt tharcfromand � ATION ,
< the hasb far the alleged exemption. Any violation of Section 7011.5 by any OUTLETSSWITCHE&FIXIURFS
Applicant fora permit subjects the applicant to a clot)penalty of not more than J
[q fjge undred dollars MD0). SQ STOWFS - TYPECONSMUCTION
1,as owner of the property,or my employees with wages as their sole NEW RCSIDENTIAL ELECTR
t7< cTmperoation,will do the work,and thestructure isnot intended or offered for
$' O -to(Sec.70K Businessand PrfgAms Code:TM Contractors License Law
r�. docs not apply toanowner of property who builds crimproves thereon,and
whodoeasuchworkhlmseforthrough hisown employees,provided that such OCC.CROUP RFS.UNITS,
improvements are not Intended orolferedforsale.If,however,thebullding or 'TOTAL:
lmpmver ntbsoldwithinoneyearofcompletlon,theowner-bullderw)l Mve
Ok¢trden of provingthat he did not build orlmprove for purpossolsale.). QTY, PLUMBINGPERMIT FEE7.7pOD7DNE 'APN
U L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
to construct the project(Sec.7044,Thoth eas and Prolong..Code:
The Contractor'.License Law doe.not apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
builds or improves themon,and who contracts for such pco)ects with e
cgp(Fctarte)Bonnard pursuant to the Contractah License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
1_J l am exempt under Sec. B k P C for this mason
'SANITARY Y N
\ Owner - Date DRAINS FLOOR ROOF,AREA,GOVit?Tql QF FEE 5
ND. f
RECEIPT
WORKMAN COMPENSATION DECLARATION FD(1UftFS PER TRAP SCHOOL FAX Y N
❑I hereby Affirm Co I have o certificate or consent to opytheum,ora RECESPI,#
t certificate of Worken'Compemwtlon lruunnreora rerti(kd copythereof($ee. GAS F.A.SYSTEM-1 INC.4OUT1,EfS PARK FEE Y -N
3800,Lab C.) r
Com M GAS EA.SYSTEM-OVER4(EA) RECEIPTN
Com any - - BUILDING DIVISION Fr.ES
BCertlRed copy hereby fumlahed. GRE15HANDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
FlCertified copy ls filed with the city inspection division,
CERTIFICATE OF EXLTIPTION FROM WORKERS' GREASETRAP PAID .
COMPENSATION INSURANCE SEWER-SANTTARY-
(Ihlssection need not be completed lithe permit b for one hundred dollars STORM EA.200FL'' Da[e Receipt#
(f100)orfen.) WATER HEATER w/VENT'/ELECTR ENERGYFEE Y N
Icertl(y that on the performance of the work forwNch this permit is Issued, —
I.hall not employ any person In any rrenner n As to become eubfect to the WATER SYSTEM/TREATING
Workers'Compenvtlon ward
Gllfornla. Date PAID '
eZZ ,Applicant NEW RESIDENTIAL PLUSH. :ORI. Date Rece1 t#
O NOTICE TO APPLICANT:](, ft rmakingthls CertBlcate o(Exem)xton,you
- should becorre eub1M to the Workers'Camperuatlon provof=afthe Labor - TOTAL:
N Cade,youmuat(orthwith comply with each provblomuor tM.pmrtNbhallM
deemed revoked. BUILDING .
00
LU CONSTRUCTION LENDING AGENCY " SEISMIC FEE a
CL O I hereby affi rtn that there bamntmction lendingagency for the perform- ELECTRIC FEE
Z ance of the work for which this permit is Issued(Sm.3097,Civ.C.) TOTAL:
U O Lander.Naom PLUMBING FEE
LLF- Lender.Aadren QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW IreNlythatIhave mad thimapplicatlonand gate thattheaboveInformation
0. bcorrec4.Iagmetocomp)ywlth allcityand coomyordinancesand mate laws PERMTTLSSUANCE FEES PAID: '
>- relating to bullding,mutructlan,and herebyauthodu representatives of thio
F— W city to enter upon the abov&owntlonei property for inspection purposes. ALTER OR ADDTO MECH. Date Recei t#
(We)agree to rase Indemnify an d keep harMess the Clty of Cupertino - - P
ago Ilabllitle.,So t ' rte and expenses which may In anywayaccrue AIR HANDLING UNIT(TO 10,010 CFM) SUBTOTAL:
ABA t Id City Inc ne en of the granting of thii P�'/"`. AIR HANDLING UNIT(OVER 1B,000CFM) - CONSTRUCTION TAX
/y-I�� CONSTRUCTION TAX PAID:
S gnatureof Applicant/ rat n r Date EXHAUST HOOD
HAZAR MATERIALS DISCLOSURE
Will the applicant orfuture hullding occupant store or handle havardous HEATING UNIT(TO 100,000 BTU)
maDate ItCCeI t# _
terialas defined by the Cupertino MuNcipal Code,Chapter 9.12,and the -
I lealth and Safety C lora 25532(a)7 FIFATING UNIT(OVER 100,000 BTU) TOTAL: is
❑lli Yn tho
We applicant o forum building occupant use equipment or devices VENTILATION FAN ISINGLE RESID) ISSUANCE DATE '
whi Mt hawrvlo lr contaminants am defined 6y the Bay Arca Air
lhy f
u�allty Managementt DlDlsMct7 - BOILHA-COMP(311P OR 160,0W BTU)
^_
I I Yrs ^�No l4�••6
Zhavercadthethil,s`affet materialstionsrecluftement.under 05,2553aChapter. 1 of BOB.ER-CDMP(DY1R 100,000 BTU)
the GIIlarnla Health& !sty Code,Sections 75505,75533 and 75534. I (q
unde rad that itthe b docs not currently have a tenant,that it is my NEW RESIDENTIALMECH. .SQ.fT. _ I -I A 1990
res m llity to tilerallyoc pant of the requirements whi must emet IFI : ^
prlo to uanre of a G Ificat anry. 1lA'\ r -
nem or authorom agent Date City
Date TOTALISSUED BY:
:.
OFFICE COPY