20745 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building 1'm'dcl ldentlfiotlon PERMIT NO.
BuilL-161ding ddreaa:GoG��oa� 20745
nera s U one: APPLICA nON SUB7rrrAT75—ATr—
rCITYOFCUPERTINO-BUILDINGDIVISION
^� Q
Contractor Na e. APPLICATION I PERMIT
BUILDING-ELECTRICAL-PLUMBINCMECHANICAL CATEGORY CONTROL
Architect/Engineer. c. o:
QTY .ELECTRIC PERMIT FEtE�.., BUILDING PERMIT INFO
Address: PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby effirmthat l amliceneed under provisions of Chapter9(commenc. APPLIANCESRESIDENTIAL JOB DESCRIPTIONIngwlth Sedion7000)of I3lvision3ofthe Businesand PmfessimsCode,and my
license is In sorer and effect. - PANELS
License Classs Lic.p
Date Contractor —UP IQ 200 ANTS
ARCHITECT'S DECLARATION 201-1000 AMPS
pr,qp++re0 O I understand my plans ahaB be used word,.as public d,. OVER 1000 AMPS SQ.FT.FLOOR
RRyAREA $/SQ.FT..
Licensed Professional SIGNSELECTRICAL
<<re OWNSR-BUILDER DECLARATION • 1 L N'
eFi, SPECLILCIACIJIT/MISC
L., owing reason.
Sectiohat m 31,5,Bxempt fromBusiness
a Conlmeor's License Any for the _
OZl.. following reason.(Section 7Bi1S,Buainesandr,Imprve, Code:Anyetyor
ir TEMP.METER 0 'ST.
county which requires a permit to mnstruq alter,Improve,demollah,orrepalr
$^ � anystructus,prior to its isauance,abso requbesthe applicant lorsuch permit to POWER DEVICES
C V file a signed statement that he is licensed pursuant to the provisoes of the
Contract.e.License Law(Chapter 9(commencing with Seaton 7DOO of Divi- SWIMMING POOL ELECTRIC VALUATION
M.the bass for
thealleedexemption. Anyvirthat lation is exempt therefrom and ��
< the basis for the alleged exemption. Anyviolationto
of penalty
o 70315 by any UTLETSSWITCHES mlRES loll
applicant for a permit subjects the applicant to a evil pevity of not rtnre Than
w flue hundred dollars hepr. NEW RESID ELEC
7 ❑I,asownerof theproperty,or my employeswith wages r their sole STORIES TYPE CONSTRUCTION
compensation 4Z BusBothe work and the structure The
not intended or offend for
pdile(not apply to Business and f property
Code: or
imtorsproves
Licensethemon law
S$ does does
apply loan owner of property who n lids or improves dhereory and OCC.GROUP RES.UNITS
who doessuch work himself or through his.wnemployen,provided that such
Improvements are not intended or offered for sale.If,however,the building orIAL:
improvement iesold wilhinoneyearofcomplMlomtheowner-builderwlil have
t"reen of proving that he did nm bund or improve for purpose olsile.). QTY. PLUMBING PER FEE FLOOD ZONE APN
U I,as owner of the property,am exclusively contracting with licensed
contractors to construe the project(Sec.7014,Business and Professions Code: PERMIT ISS[J`NCE
The Contractor's License Law does next apply to an owner of property who
bunes mo -
ALTERDRAW k VEM-WATER(EA) ` W
Wild.or Improvthereon, and who'cormacts for such pcta with a FEE SUMMARY-
co,,[[LLl[[aew(a)B¢Used pursuant to the Comments's LiermM Law. BACK FLOW PROT[CT.DEVICE
LJ f am exempt under Sec. B k P C for this reason
OUTSI OF III:S
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner ran¢ Date RFOFRxf X
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y_ N
hereby affirm That I Have a¢rtin¢te of cgnsent t.self-Insure,Ora FIXNRES PER TRAP ?t RECEIPT X
innate g(Workeri Compensation ensu macerti(kd copy them.f(Stc. GAS EA.SYSTEM-I INCA OUTLE IS e� PARK FEE Y N—
W
lab CJ —10 RECEBTX
policy p GAS EA.SYSTEM-OVER 4(EA)
Com any - BUILDING DIVISION VISION FEES'
Certified copy U hereby furnished.
Certified copy H filed with the city ty InspeeHon division. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
`y'
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASE TRAP PAID? L�Q4 rQ97
COMPENSATIONINSURANCE SEWER-SANITARY-STORM EA.20OFT. Date RCtt'1 t# .Upfs"L
(This section need next be completed if the permit lefar one hundred dollan
($100)orlem.) WATER I{FAIFR W/VENT/ELEOTR ENERGY FEE Y_ N_
1¢rtify that In the performance of the work forwhich this permit Is issued, t�yI•
1 shall not employ any person in any manner so s c s .to the WATER SYSTEM/TREATING �"I tO J\X
Workeri Com n w�yf Ga iff . Dale PAID – w av{,�
O Z Appu an�E NEw RE9DENr ALr M8. SFT. Date Re
Z O NOTICE ICANT:R,after riaklngthis Certificate.f Esemplion,you
should become subject to the Workers'Compereation provisionsof the Labor TOTAL:
P
N Code,you mu at forthwith comply with such provisions or this permit shall be BUILDINGco
LU > deenN revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE O�
Il Z Iherebyaffren that there Is aconstruction lendingageng forlhe perform TOTAL: /� ,ay� ELECTRICFEE x
once of the work for whleh this permit t9 isse ed(See.3097,CIv.CJ 0.
V O Lender;Name - PLUMBING FEE OLQ�
LL
F Lender',Address QTY.I MECHANICAL PERMIT FEE
MECHANICAL FEE-
, O W ormet.Iagrehavereply with
allcityndcounte tordina abovedMateation
am
1 fs wired.building complywRh a ndhereyauhome represent it
Mate lam PERMIT ISSUANCE s00 FEES PAID:
relating to building conswction,and d prop rty or mere resentaHvea of this
N city m enter upon the above-mentioned properly fornrepe'sm purpoaea. ALTER OR ADD TO MECH. �yratl
Z (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
L.I against liabilities,Ndgment,,costsand expenses which may lnanymyaccrue AIR HANDLING UNIT(I010,000 CFM) SUBTOTAL:
against slid City in consequence of the granm t pe ppy
AIR HANDLING UNIT(OVER I0,000CIM) CONSTRUCTION TAX -
Igruture of Applicant/Contractor C Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: _
HAL RDOUS MATERIALS DISCLOSURE
Will the applicant or future budding occupant store or handle hazardous HEATING UNTT(TOI00,000BTU) Date Recel t#
materul as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I{eahh and Safety C Ion 255320)? HEATING UNIT(OVER 100,000 BTU) TOTAL: O
❑Yn
Will theappiicanlMuni building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) �sW ISSUANCE DATE
which rout haznrdou,air contaminants as defined by the Bay Ars Air - �pR�
Quality Mawgtmento BOILEp
R-COMP HP OR 100,000 BTU) J{—is�0
Yes
have read the hada ou,materials requirements under Chapter 6.95 of BOILER-COMP(OVFR 100,000 BTU)
the Callfornla Health Safety Code,Sections 75565,755]3 and 25534. 1 E'!c 17 1890
understand that ifth Ieing does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requirements which must be net
pnorto issuancr,Ia rtilicat O atpancy. - '
f 6xG ,=-. r cf r��,�, Thrn�o� 1j 1
cy m mgr d➢ a Dale ISSUED BY V
/ OTAL:
OFFICE COPY `