20698 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification - PERMIT NO.
Building Address: r n 0 O
787s l! 1v t urf G o
weer ante: one: - A
Z_ .CITY OF CUPERTINO BUILDING DIVISION EJ"L/j�
Contr r' ante Lk.No: 7 APPLICATION / PERMIT qr L
6 BUILDINGELFCTRICAI.PLUMBINC-MECHAMGL CATEGORY CONTROL
Architect/Engineer. V Gc.Na:
OTY ELECTRIC PERMIT FEE BUILDINGPERMIT INFO
Address: _ / PFRMITISSUANCE El
LICENSED CONTRACTOR'S DECLARATION
I hereby aHirrnthat l son licensed under pmvisionsof Chapter 9(commne- APPLIANCESRESIDENTIAL JOB DESCRIIaT10N
Ingwlth Se ion70(ID)of Division3ofthe Budmmand PmfnsimsCode,and my -
ila In(ul rca and effect: PANES
Lcen
licam lase Lke
Data Contractor 12 IQ 200 ANTS
ARCHITECPS DECLARATION 201-1000 AMP$
a0 O I understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR'AREA §/SQ.FT.
Licensed Professional SIGNS ELECTRICAL -
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
thereby affirm that am exempt fmmthe Contractor's License Law for the
p qqqq following reason.(Section 7031.5,Business and Prefessions Code:Any city or
�ZI"'ty cauntywhkhrequreeapermltwwmtmd,alter,impmwdemolbh,orrepalr TEMP METER OR POLE[NST.
anystmdure prlorta its Issuance,alae requlreatheappBnntforsuch permatto POWER DEVICES
6 ryG file a signed statement that he Is licensed pursuant to the provisions of the
Contractor's License Lawha er9(commendn 000
with Section 7 )of Divi- SWIMMING POOL ELECTRIC VALUATION
�0 Aon3 ofthellusiness and Profemlome Code)orthatt he In exempttherefmmand
;! 6 the balls for the alleged exemption. Any violation of Section 7MIS by any OUTLETSSWITCHESFIXTURES
applicantfor.permit iubjectstheapplicanitoadvil penalty ofnot mmellum
pj o fiFIL asve ownered ofthears prop NEW RESIDENTIAL ELBCTR' STORIES -TYPE CONSTRUCTION
QQQ paasowner o(tMproperty,orhe employees Is with wages as their sale
mm(Sec.7 K Businewill doss
sahe workandthestmdurehe C Intended License law O sale(Sec. pply to alnowandf property Code:The Contractors Urerae law
who ddoes oes
apply wean ownerofprough who nemporimprovnted that such
- OCC.GROUP RFS.UIJIT5
Impro suchworkhlmeelforthmugh Meownemployeef,Provided thatsvch
Improvemenware notintended orofferedforsale.If,however,thebuildingor L• -
Improvementbaokt wlthlnoneyeaiotcompldlon,theowner-bullderwlll have -
ti�urdenofprovingthathedid rotbuildorimproveforpurposeofsale.). QTY. PLUMBING PERMIT FEE
L J D TONE APN
Las o.on r
tr the property,em exclusively Business
and
with nCode:icensed PERMIT ISSUANCE
TheconCorors to co Licanwud Lawdproject notec.apply t einn one of pro oro Code:
The Coor Improves
es thea Law don who
apply to an owner o;property who ALTER DRAIN&VENT WATER(EN
bulkls t r improvse thereon,and who contracts for each plojedd with a - FEE SUMMARY
onador(s)xemint under Sntrothe Con[ractor'e License PLaw. BACK now PROTECT.DEVICE
Lj I am exempt under Sep B &P C for this renon
.. DRAINSFLOOR ROOF,AREA.GOND. SANITARY Y N
Owner Date RECEIPT p
WORKMAN COMP ENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX -Y- N
hereby affirm that I have a certdlaw of consent roself-Inaer"ora RECEIPT N
certiflnte of Workers'Compenatlan lraoranceora ccrtIn mpgythereot(Sse GAS FA.SYSTEM-1 INC.4OUTLETS PARK FEE' Y N_
I'm Lpb C.) rM rL(ll�f� l•� - RECEIPT p
Com anv GAS F.A.SYSTEM-OVER4(EA)
[} �J )�nJ BUILDING DIVISION FEES
dCertlOed copyb nEre Tumlahed. EPTOR
;F'redNed ropy Is filed with the city inspection divion
si .
GREASE/INDUSTRL WASTE INTERCPLANCHGCK FEE CERTIFICATE OF EXEMPTION FROM WORKERS' GRElSETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FL. Date '' Recei [#
(Chis section need not be completed[Rhe permit is forom hundred dollars
(§100)orle®.) WATER HEATER W/VENT/ELECTR ENERGY FEE 'Y N
I certify that In the performance ofthework forwhich this permit is issued,
I shall not employ any person w any manner so as to become subject to the WATER SYSITM/TREATING
Worken'Compensatlon Laws of California.Date PAID
0 Z NOTIAppliCE _ NEW RESIDENTIAL PLMB. SQ.FT. Date Remi t#
Z O NOTICE TO MPLyrt to
aflerars'Co perationhin 1procate ofExemption,oft
eLyou
Code, become subject to the Workers'Cum provisions
n premiss u of the Labor TOTAL:
W Cade,you must forthwith comply with such provialore orlhis permit shall be
W > deemed revoked. BUILDING FEE
LU C CONSTRUCTION LENDING AGENCY _ SEISMIC FEE
IherebyafRrm thatthere is a construction lendiagagency forthe perform, TOTAL: ELECTRIC FEE
n Z ance oftheworkforwhkW
hlhis permit is Issued(Sec.3097,Civ.C.)
CU 0 fender's Name - PLUMBING FEE
F Lender's Address. QTY. ' MECHANICAL PERMIT FEE L
LL MECHANICAL FEE .
O W arrect. thatI Iagracto co plywapplcitynand dcoutelhattheso.ce.ve lnfomaaws -
(L bmrmm lagreeto complywith all ndlyandcothoola reprenand stat el awe PERMIT ISSUANCE /a aU FEES PAID:
}
relating
oenterbuilding mra4udrontioned reby authorize reprexnpurpos of this - - -
(_ N cityW)aree to save,
l an
propehameWpe Cit purposes.Fortino
ALTER ORADD 70 METH.
2 - Date Recei t#
V (We)agree to save, encs, m s and keep harmless the In a of Cupertino
against Rabi lea,judgments,mate and expenses which may Nanyway aceme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
xgzbat uld'Qlty Inc sequence of the granting of this pT�rpIt.
_✓114- /a�q/A�� AIR HANDLING UNIC(OVER 10,000 CFM)- CONSTRUCTION TAX
Signature—of Applinnt/Contractor % mate EXT-AUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or hand le hazardous r HEATING UNIT(TO 100,000 BTU) D Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.1$and the
Health and Safety Coca Yes , +—S,Iection 25532(s)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: k
N.
"❑Wlltheeppikant or future building ocmpantuse equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
whichwhich emit hazardous air contaminants as deHmd by the Bay Area Air
cMawgemeM Doistdd7 ' BOILER-COMP pI�'OR 100,OW BTU[
I I Y. d No ^
ave read theFazar ous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) ("^
the California Health&Safety Code,Sections 25505,25533 and 75534.I
and etstand that if the building does not currently have a tenant,that It is my" NEW RESIDENTIAL MECH. SQI T7 t•
- responsibility to notify the occupant of the requirements which must be mat a,
prior to Issuance of a Certificate of Occupancy. ;G fOC��
V
' CV.MKfJ
Owner or authorized agent Data d SSUED BY
TOTAL: I
OFFICE COPY