21002 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
i
Building Project Identification
PERMIT NO. .
BuBding Address:
�9> zz x0 2100
re ams: one: A
'aO So�✓ �' ��' >Y37 CITY OF CUPERTINO-BUILDING DIVISION
Co lractw'eName: //�/J LIc,Ne: APPLICATION it PERMIT
YS )7 S BUILDINGELECTRICALPLUMBING-MEC}IAMCAL CATEGORY CONTROL p
Arc ct gineer. Lk.No:
c/�✓�j>x.-���t $ Ga61<Tr
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE 2c� ❑ ❑
LICENSED CONTRACTOR'S DECLARATION'
I hereby offm,that l am licenced under provisions ofChapter 9(conorrome. APPLIANCEB.RESIDENITAL J08 DESCRIPTION
Ing with Section 7DOO of Division 3 ofthe Businesaand ProfesslonsCode,in lmy
BE.
isIn�(/u�VyJap`rcs/and d(ect. PANELS
D.la j / Ctua
Date / Contractor ✓d
ARCHITECI'SD R ION 201-1000AMPS
LM TO 200 AMM
aO ZpZO I understand my plans shallbe used as public records. OVER 1000 AMPS SQ.Fr.FLOOR AREA $/SQ.FT.
d(/ Licensed Professional SIGNSELECTRICAL
6 OWNER-BUILDER DECLARATION SPECIAL CiRCU[T/MISC
2t, � I hereby affirm thatI am exempt fromthe Contractors License Law fmthe
O E. following reason.(Section 70]1.5,Business and Professions Code:Any city orEl qq�(p METER OR POLE[NST.
�� El county which requloss a permit to corstmct,alter,Improve,demolish,or repair
any structure prior to its onaurce,alm requires theapplicant for such permit to� POWER DEVICES u (� file a signed statement that he Is licensed pursuant to the provisions of the
3O� Contractor§License Law(Chapter 9(comorming with Section 70011)of Divi-
sion SWIdMING POOL ELECTRIC.
3 of the Busioese and Professions Cade)orthat he V exempt therefromand VALUATION
the basis for the alleged exemption. Any violation of Section 7001.5 by any
QOM eppVnre
cantforapermitsubjectstheapplicamtoacivilpenaltyofnutnthan 2,DDTLEISBNOTGHESFIKTDRES Ipd V
e' m five hundred dollars($500). NEWRESIDENTIALELECTRSQ.FT. - STORIES TYPECONSTRUCTION
�n ❑I,as owner of the property,or my employees with wages as their sole
con' "'I willdo the work,and thesmacture R not intended or offered for
sale(Sec.7014 Business and Professions Code:The Conlracioes Llcerae Law
r3'$ does not apply to an owner of property who builds or(mpowes thereon,and .
whodocsmchworkhimsetforthraughhleownemployces,pr idedthatsuch OCCGROUP RFS.UNITS
Improvements are not intended oroffered forsale.If,howevegthebullding ee TOTAL:
Improvement Issold within oneyearofcompl&ion,the owner-bu8derwill have
tFalmoden of proving that he did not build or improve for purpose ofsals.), QTY, rPLUMBING PERMIT _FEE FTAOD ZONE APN
Lj 4 as owner of the property,am exclusively contracting with licensetl PERM I r� 11 /V
contractors to ronstmct the project(Sec.7014 Business and Professions Code: Fr
The Contrector'e License Law does not apply to an owner of property who ALTER-D N&VENT.
builds or Improves thereon, (EA)n, and who contrafor such ptojem,with a - -gB[fFEE
oactor(a)licensed pursuant to the Contractor's Limnos Law. BAIXiFLO AROTECT.DEVICE?
SUMMARY
LJ I am exempt under Sec. B&P C for this reaeen
DRAT S ..p AREA,CON . I Q Q SA ARY Y N
' OUTSIDE FEES
Owner Date r
WORKMANRECEIPT If
COMPENSATION DECLARATION PER TRAP .
RECEIPT
❑I hereby affirm that I have a certificate of consent to self-Insure,ora LTA% Y Y_ N
N N
certificate ofWorkma'Comp eanstfon Insurance or a certified copy thereof(Sec.
380,Lab C.) - GAS-EA SYSTEM IINC.40UTLEiS J PARK FEE Y N
Policy M RECEIPT if
oon any i ✓ GAS FA,SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
�1Allied copy is hereby th the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑
Certified ropy U/lied with[be city Inspection division.
CERTIFICATE OF IXEMPTION FROM WORKERS' GRE-ASETRAP , PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 20GFT Date Recei t#
(Ihissess.) need not be completed lithe permit is for one hundred dollars
(f100)rtifyt J WATER HEATER W/VENT/ELECTR 'ENERGY FEE Y N
[certify thatlnthe parseuinany mannee workr
an as to this become mit Is subject
—
I shall not employ any perean In any manner ate u to became subject to the WATER SYSTEM/TREATING
Workers'Compensatlon Laws of California. Date PAID
O Z Applicant
Z O NOTICE TO APPLICANT.If,after making this Certificate ofExemption,you NEW RESIDENTIAL PLMB. SQ.FT, Date Recei t#
should become subject to the Workers'Compenadiae proven=oRhe Labor TOTAL:
~ 00 Code,you most forthwith comply with such proWlors or this permit shall be
LU j deemed revoked. BUILDING FEE co
d 0 CONSTRUCTION LENDING AGENCY SEISMIC FEE L
I herebyaflme that there is a construction lending agency for the perform- ELECTRIC FEE
M O once of the work for which this permit is Issued(Sec.3097,Civ.C.) TOTAL:
L) Lenders Name PLUMBING FEE
LL F Len care Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Iceditylhatl have readthisapplicatonand statethattheahovelnfomuHon
IL Isocreact.I agree to comply with act city and county ordinances and stall laws PERMIT ISSUANCE FEES PAID:
). U) relating to building corotructlon,and hereby authorize representatives ofthis
H Z citytoenterupon the above-mentioned property for inspection purposes. ALTERORADDTOMECH. Date Recei t#
V (we)agree to save,Indemnify an d keep harmless the City of Cupertino P
against liabNties,judgments,costsand expenses which may In anywayaccrue AIR HANDLING UNIT(To 10,000 CFM) SUBTOTAL:
aga Inst said City in consequence of the granting of this permit
�IIAIA HANDLING UMT(OVFR 10,000 CFM? CONSTRUCTION TAX
y Sgoamre of Applicant/Contractor Data EKHAUST HOOD(W/DUCT CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a pplica m or future building occupant store or hand In hazardous HEATING UNIT CIO 100,000 BTU) Dale R2Ce1 t#
material as defined by the Cupertino Municipal Code,Chapter 9.1$and the
Health and Safety Code Section 2S532(a)7 HEATING UNIT(OVER 1(0,000 BTU) TOTAL:❑Yea No
Will the applies.or future building occupant use equipment or devices VENTILATION FAN(SINGLE READ)) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
a lity Management Dislrfct7 BOILER-COMP QHIP OR 100,000 BTU) PAID'
4No
' have read the hazaYousmaterlals requirements under Cbapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health&Sa fety Code,Sections 25505,25533 and 25534.1 SEP 10 �J�O
and enotand that if the building does not currently have a tenant,that it k my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requirements which must be met
pd.rliq ssuancgofa Certlf eofOccupancy.
Owner ora Drte ISSUGD BY:
TOTAL:
OFFICE COPY
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