20733 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES,— USE BALL POINT PEN ONLY
Building Project Identification _ PERMIT NO.
Butdmg Address:
o G I33• ' ^O P7 f'g 17
--- one: A
nCITY OFCUPERTINO-BUILDINGDIVISION, .
W tt`ra
sn�l° Lm.Nn: APPLICATION / PERMIT
BUIL6INC-ELECTRICA4PLUMBINC-MMCH LAICAL CATEGORY CONTROL#
Anemia glneer, Ie No:
Qn ELECTRICPERMIT ''EPEE', BUILDING PERMIT INFO
Address:
PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTR SDECLARATION
I hereby affirm that lam Bcrnunder eed underprovalans of Chapter9(commrnc MI'LIANCESRFSIDENITAL - ROB DFSCRIPTION
ingwith5e fu 7000)of deffeon3otthe BuslneeandPro(esslonsCode,and my
limns¢le In(u d dies[. ' ` PANELS I � u, ��J
la _ Llc,p
Date'
Date' Contractor
ARCHITECI•SDECLARATION 201"1000 AMI'Ss
q�q�uu 0 sZ I understand my plaru shell used es pu
be uablic records. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
Fz I'j Licensed PrefessimalSIGNS ELECTRICAL .
<ILgu OWN3R-BUILDER DECLARATION SPEC CIRCUIT
2 F,r�i'3 I hereby a(Erm that I am exempt fromthe Contranors Llanx Law for the
rs following reason.(kdim 7[01,5,Business and Profmiom Code:Any dty or
F 33+1 c ntywhlchrequlmnapert ttomrutrud,alter,impmve,de=lish,orrcpair TEMP' S
anysbudure prlorlo Its hemance,alsorequires the applicant for such permit to
file a signed statement that he,is,licensed pursuant to the prm,ha m of the POWER 'S
�u, Contactorf Licewelaw(Chapler9(mmmenMg wkh Section 700Bof Dlvl- SWIMW LELECTRIC
slan 3 ofthe Business and Professions Code)or that he is exempt therefromand VALUATION
the Wsls for the alleged exemptlon. Any violation of Section 7Rf15 by any OUTLETSSWITCHESFIO'URES
G
applicant for a permit subjectstheapplicant to a civil penalty of not more than -
five hundred
sownerdollars ofthep0). NEW RESIDENTIAL ELECTR SQFT. STORIES TYPE CONSTRUCTION
�j ❑I,as owner of the property,or my employees with wages a their sole
compensation,wOldo the wo,"rul thestruclure is not intended or offered for ,
0 sale(See 7044,Business and Professions Code:The Contmm?`sLjcetne Law
$� does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RIS.UNITS
whodoessuchwork himself orthrough hisown employees,p ceekledthat such
Improvements are not intended oroffemd forsale.If,however,thebullding or TOTAL:
Improvement issold withinoneyoarofcompldloglheowner-builderwlll have _
[Burden of proving that he did not build or Improve for purpose of sale.). QTy. i —PLUMBING PERMIT-'' ,',FEE , FTAOD7Arw APN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to comtmd the project(Sec.7044,Business and Professbm Code:
The Contractor's License law does not apply to an owner of Property who
builds or improves thereon,and who contracts for such ptojects with a ALTER-DRAIN&VENT-WATER(EA)
_ du
aram m
)licensed pursuant e Contractors License Law. t FEE SUMMARY.'
y1(n I am exempt under Sec B&P C for this reason BACK FLOW PROTLCL DEVICE
DRAINS FLOG ROO$A SANITARY' Y_ N
Owner QIITq1I1V PITS
Date R REA,COND. R1iCm"T N
-WORKMAN COMPENSATION DECIA RATION FIX'IVRES PER TRAP SCHOOL TAX Y— N
Of hereby affirm that I have a mrtl0ate of consent to elf-Inure,ora RECFJ!'(M
certificate of WorkerYCompeneatlon leaurance or a certified copy thereof(See. GAS EA. INGd OUTLETS
3800,Lab C.)• o PARK FEE . .Y_ N_
.Policy p _ - - RECEIPT#
Com an GAS EA.SYSTEMOVER 4(EA)
� Y BUILDING DI V ISION FEES
CertlBed cop herebytumecity GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
mil Ccrtlfidropybflled with the city inspection division. '
'CERTIFICATE OF E%EMPIDON FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(rhlsadon need not beduepldcd lithe permit lsfeone hundred dollars SEWER-SANITARY-STORM FA.200FT. Date Remi t#
(5100)orless.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I ll notcertilyemphatloy
an person In an the fe,as to became,
a permit is board, —
I shall not employ any person In any mannerao u to beromn subject to the
Workers'Compensation laws o( ATER SYSTEM/TREATING
California.la.Date PAID
O Z Appllcant
Z O NOTICE TOAPPLICANT.e,after es'Co pe cation Certificate of Exemption,oftheyou
NEW RESIDENTIAL PLMB, SQ.FT, Date Retci t#
F Code,shoulo mmesubFdto the Work en'such pmvMou rovhbi permit
s Labbe TOTAL:
W CWGdre must forthwith comply with such provalom ormh0 permit shall be BUILDING� j deemedrevoked. _
(LG CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm that there a a construction lending agency for the perferve ELECTRIC!FE'FU
7 Z anceofthework for whichtha permits Issued(Sec.3097,Clv.C) TOTAL: �xQ)
U 0' Lenders Name y PLUMBINIL LendersAddress QTY;'ytt •MECTIANICAL PERMIT, rFEE, MECHANOW Imnlfythatl have read thisepplicatlon and stalethatthe above Information -a scorted.l agree to comply with all chy and county ordinances and state laws PERMIT ISSUANCE FEES PAI>. relating to building construction,and hereby authorize representatives ofthaZ city to enterupon the above-mentioned property for bupectbn purposes. ALMORADDTOMECH. DateReCei t#
(We)agree to ave,bdemnlfy an d keep harmless the City of Cupertino Pagainst llabllitles,jadgerents,costs and expenses which may In anyway accrue AIR HANDLING UNIT(TO 10,ODO CFM) TOTAL:
ago Wt City In commIg of the grant) g his permit tT
1 Q AIR HANDLING UNIT(ovelR lo,BoocFMf) CONSTRUCTION TAX
Beaman,of Applicant/Contrador Cloth EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUSM ERIALSDISCLOSURE - -
-
Willtheapplicantorfuture building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recef t#
material as defined by the C rtlno ModI Code,Chapter 9,12,and the _
Healthxnd Safely Code dion25532(a)7 Hili1TING UNIT(OVER 100,000 BTU) TOTAL:
Yes Na
-- -Will the applicant or future building occupant use equipment ordevlces VEN"fILAHONFAN(SINGLERESID) o ISINWATE
which and hazardous air con nanlsaade(Ined by the Bay Arca Air . '
Quality Maagchndt DBt BOILER-COMP OFNOR 100,0(0 BTU)
Ya u
ca
F have read the haousmateriaLsrequlmr ntsunderChapter&95of BOILER-COMP(OVE2100,E00 BTU)
rhe California Health&Safety Cale,Sections 75505,25533 and 255.34. I V
" understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH.• SQ.Fr. ,,F
mapmoiblllty to notify theoccupant of the requimments which must be met �• of Cunei Sino.
or to once of a CertlO teof0 panty _ I .i + _
mer or aul mi,ced agent Date'
TOTAL: 155UED OY:
OFFICE COPY