20568 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification , PERMITNO.
Budding Address: n O 1' (�
assn: lT 'V1 ITJS
CITY OF CUPERTINO-BUILDING DIVISION �j
. tl� Ivirf �[Ly1c•N APPLICATION / PERMIT 6— ��'CON
�QI(S r'� BUILDINGELECiRICA4PLUMBINGMECHAMCAL CATEGORY CONTROLX
Am Itect er� L Llc:No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PpAUTISSUANCE 1V� ❑ ❑
by a LICENSED CONTRunder SDECLARATION -
IhehScctIn7000).rm'hat lam Bcensefth.Buinma dPmfe eons Code,and re.my APPLIANCES-RESIDENTIAL JOB DFSCRE'DON
in ..I,edlan 7000).f DIWa.n3o(Ihe Buslnessand Professlom Code,and my
L icor e b in lull fo d effect er-- PANELS
Date Clam Lmu �f
Da(e_ `j•_ nAConincor_ a .�Ce.lf4UP TO 200 AMPS
tis
ARCHITECT'Sashesused
OVER (AMPS
1Q+�aO Zp Iundersnnd my piss shall be used upublic recordx OVER 1lD0 AMPS SQ.Ff.FLOOR AREA 5/SQ.Ff.
E d Licensed Professional SIGNSELECTRICAL
6 OWNER-BUILDER DECLARATION
1 h $IsECIAL C]RCUIT/M15C
ereby affirm that I am exempt fromthe Contractor.License Law forthe
pp following reason.(Section78315,Bualnessand Profeselons Code:Any city or
cmntywhlchmquimsapermlttommtme,alteplmpmvgdem lbh,ormpalr ?TMP.METER OR POLE INST.
q� ❑ any.tacure pdortolts Issuance,also requirestheappllunt forsuch permit to
ES file a signed statement that he t Ilcen.ed rsuan
put to the provalov of the POWER DEVICES
G610u,IContractor's License law(Chapter9(commencing with Section 7000)ofDivl-
n SWPiMING POOL ELECTRIC
SOS 'he ba (the the alleged exemption.
xemption. AnyCodeviolator ion
n of exempt therefrom and VALUA710N_
O the bast for the alleged sects the
a Any violation of Beldon nor room
by any
GI
applicant fora permit subjectsapplicant toa civil vl f otmore than OUTLETSSWITCFTESHKTURES eJ C(�•J
PP el 1Mpenalty o n
$ five i,asoddrofthe500). NEW RESIDENTIAL ELECTR
�n ❑Lvow,willd the work,
riy,ormy, employees Jaswlihwagssa. ffered for
ebsole �'�' STORIES 7YPE CONSTRUCTION
-In
compensation,Business
and rka.d lhestrotle;TheC Contractors
orcenseLw L
Q sale(Sec.apply
to alnow owner
Profession who
or Impco'.ors theorm lad
[Bj $ whoa notapply torn owner of throngproperhis o nemporlmpmovided that
and OCC.GROUP RES.UNITS
0.0. whodoem nts am work himself ort through hleowne.If,hon, ee,the build
Ing or
Improvement sold intendneyeared or fcompletioered for the owevep deer ldingoe TOTAL: C
improvemrenttwld wlthinoneyearofcomplMlonraise owner-builderwlll have '
t4t,vrdenofpmving that he did not build orionprove for purposeoisaled, QTy. PLUMBINGPERMIT FEE p(ppp PONE ApN
L L as owner of the property,am exclusively contracting with hourned
contractor,to cera uct the project(See.7064,Business and Profeselons Code: PERMIT ISSUANCE
The Contender.License law does set apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
buBd. or Improves thereon, and who contracts for such projects with a
yIllLflacmr(.)If...d ec pursuant In the Contractor'.License Law.
[5BACK FLOW PROTECT.DEVICE FEL SUMMARY
el am exempt under SB 4 P C for this reason
DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y. N
Owner Date RECEIPT N
WOR
WAN COMPENSATION DECLARATION FIXTURF_S PER TRAP sCF SCI100L TA% Y_ N
❑1 hereby-fibro that I have a cerdficate of consent to.elf-insure,or a W RECEBT N
certificate of Worker.'Compevation Insurance or a unified repythereof(Sec.
3800,Lab C.) - GAS EA. -1 INA OUTLS PARKFEE Y_ N_
Policy N RFLEI T 0
Coe GAS G. -O
❑CenlBed copy t hereby tBUILDING
DIVISION FEES
❑CenlRed copy t(fled with the city Inspection division. GREASEAN U A OR PLANCHECKFEE
CERTIFICATEOPEXEMPTION FROM WORKERS' GREASE TRAA, PAID _
COMPENSATION INSURANCE _SA y- Date Reeei tN
(This section need not be completed tithe permit t forons hundred dollars
($108)or less.) ATER w/ ENERGY PEE Y N
I cenifythat la m
the perfoarmof the work for which this pemNt is issued, N—
I shall not employ any person In any manner so as to become subject to the NG
Workers'Compersatlon laws of California.Date PAID
O Z Applicant
Z O NOTICETO APPLICANT.If,after raking thisCertificate of Exemption,you NJWWENi7 B. Date Remi tN
Hshould become subject to the Worken'Compematlon provisions ofthe Labor TOTAL:
V3 Code,you most forthwith comply with such provisions ortht permt.hall be BUILDING
decned revoked. '
CLCONSTRUCTION LENDING AGENCY SEISMIC FEE L
I hereby affirm that there t a construct..lending agency for the pertorm- ELECTRIC FEE
7 Z anu of the workfor which thtpermit t beueC(See.3097,Cl..C.) TOTAL:
. 0 O Lender's Name PLUMBING FEE p
LL H Lendcr.Addren QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Iunify that l have read thtapplicatlonand stanthzt theabove Information
S is correct.l a gree to complywlth all cityand county ordinances and slate law. PERMIT ISSUANCE FEES PAID:
relating tobulldtng contraction,and hereby authorize representatives of tht
I.— 2 city to enter upon the abou,mentlonM property for Wpectian purpom. ALTER OR ADD TO MECH. Date Reeei tp
— (We)agree to save,Indemnify an d keep harmless the City of Cupertino P
against Babillths,I rignems,msts and expenses which may In anyway accrue AIR HANDLING UNIT(TO 10,"CFM) SUBTOTAL:
against said City In nano of the granOn mist permit.
AIR HANDLING UNIT(OVER I Q"CIM) CONSTRUCTION TAX
Igna fAppBcant/Can r— Data EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant.,Mo.buildingomp..t store or hand In hazardous HEATING UNIT(TO 100,000 BTU) Dale Reeei tIY
material as defined by the Cu perttno Municipal Code,Chapter 9.12,and the
Health and Safety Code Stolon 25S32(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes N No
Will the applicant or future building occupant use equipment or d evices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which coat hazardous air contaoav nD as deo and by the Bay Area Air
lity Management Dinstriet? BOILER-COMP QHP OR 100,000 BTU)
Yea
No
. shave mad the hazam�ousraterialsrequlremenot der Chapter 6.95 of BOILFR-COMP(OVOt100,000BTU) �U,d 1 4 9��
the Califomla Health k Safety Code,Sections 75505,25533 and 25534.I
understand that lithe building does not currently have a tenant,that it Ismy NEW RESIDENTIAL MECH. SQ.FF.
responibility,to notify the occupant of the requirements which moat be met n'
prior to issuance of a Certificate of Occupancy. - -r(I'�, C_{�,CUpferfinQ
v
Owner or authorized agent Date ISSUEDBY:
TOTAL:
OFFICE COPY