14902 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY _
BUILDING-ELECTRICAL PERMIT NO. ^ ^ O
CITY-OF CUPERTINO APPLICATION/PERMIT PLUMBING-MECHANICAL L {J,1 L
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUIL NG AD KESS: �' S SANITARY NO. APDL=CATIONSUBMITTALDATE
`_,II r UNITM LOT# �
OWrNA ^� PHUNE.: - �'J6 CONTRACTOR'S NAME: LIC NO:
G 1 4CL NIC .�/f ^CONTROL#
ARC T Nk�U S y E ADD 5: E / i-y 7.
CONTACT: PHONE: BUILDING PERMIT INFO
J��� T�►� ��✓L Y.I QTY. ELECTRIC PERMIT L ELECT PLUMB MECJI
PERMIT ISSUANCE •�
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOBDFSCRIPTION -
LTCZ I hereby affimtthat l am licensedunderprovisionsofCMpter9(e mmencingwith - - e
0.100 Section 7001 Division 3nf the Business and Professions Code,and in,license is in PANELS x
y.0V]C full force and eHm
e .
6 CJ License Class Lic.# UPT02MAMPS
Date Contractor 201-1000 AMPS FL RAREA E/SQ.FT.
zUiZ ARCHITECTS SQ.Fr'.DECLARATION OVER 1000 AMPS
CZ-0 I understand my plans shall be used as public records. , /rA "J
9SIGNS ELECTRICAL
r,m k J mfe ^1/�i-
C Licensed P99lonal
Y a'< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
�O0sp I hereby affirm that 1 am exempt from t P meedmis Co License Law for the
VJ'3 0.y following reason.(Section emsen,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
f50 which requires a permit re oust ut,aper,improve,demolish,or repair any gned momsarommus #
pritmossicensedpursuantto eProvisionsompt for such Permit 1.theCotractrsLieaseLaw(Chapter POWER DEVICES
94_ �
C O Ont he la licensed pursuant to me provisions of the Contractor's License Lew(Chapter
a o�' 9(commencing with Section 7")of Division 3of Ne Business and Professions Cade) SWIMMING POOL ELECTRIC VALUATION
or that he is exempt therefrom and the basis for the alleged exemption.Any violation of �/ DD
Y Section]031.5 by any applicant for a permit subjects the applicanttQ
o a civil penalty of OUTLETS-SWITCHES-FIXTURES
n than Bve hundred dollars($500).
A NEW RPSIDENTIAL ELECTR _SQ.PT. S RIES TYPE CONSTRUCTION
Ithewrk,undeestrucy,e land intended
dconflwed onsthe(See.compensation,
p, ill thework,and the he Coeisnot is License
Law doses,
apply to an Business r
and Professions Code:The Convenor's License Lew dees not apply lf an owner of
propertywhohuildsorimprovesthemon.and improvemmts notitendk roffe dit s e.M1is OCC.GROUP RES.UNITS
employees,p building
orimprovehim is
entsarenacycar fs omftion,the own If,
however,the building burden
oft two ie sold a didnot build of completion,the owner- T
builder will have the burden of proving that he did not build nr improve for purpose of '
suleJ. QTY. PLUMBING PERMIT FEE PLOOD'LONE "N
❑ hasownerofthe propeny,em xclusively cunvaning with licensed con[rectorsto
construct the project(Sec.7044,Business and Professions Cot The Contractor's
License Wwdoesnotapplytoanownerofpmpenywhobuilds orlmprovesthereon,and PERMIT ISSUANCE
Who Contracts for such projects with a compreembn licensed purso- Im Contmcmr's ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
License Law. _ _+ _ p �{
C lamexemptunder Sec. ,DBt&PC for this reason BA KEL II11II�II�'PFFPpp����''``xx�fttl{I{SC"N'1 ®" 1p'� y I SANITARY O�RECEIPT# N
DRAINS OO R,OtW' rIxeb 11 SCHOOL TAX YN
WORKMAN COMPENSATION DECLARATION 0
f
❑ Ibercby nffinn thmlhav<e cenificamofconsent to selGine...ora etnifesseof FIXTU IT ) RECEIPT#
Wnrkers'Compensation Insurance urn certified copy thereof(Sec.3800,Lab C.)which ��n�1 ✓s t 1., __ ]� ARK FEE YN
V _
covers RECEIPT#
all employee's under his pcnnit. GA -BA.SY.CI'01aNC t GUILE BUILDING DIVISION FEES
Policy#
Company
❑ Certified copyishereby famished. GA .SYS 7Liv2.1ilt,-rtYirSy� ,t��-� — _ - LANCHECK FEE
❑ Candied copy is filed with the city inspection division. GREASEANDUSTR6 WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thissemionncednot be,completed lftbepermit is fames hundred dollars($100) SEWER-SANITARY-STORM EA.201 ENERGY FEE �41)
o'bou")
Icertifythat in the performance.fthe work forwhichdni pemtitis issued,10.11 WATER HEATER W/VENT/ELECfR
not employ any person in any manner so as to become subject to the WorkersPAID
72757
Compensation Lawsof Califomra. Dara WATER SYSTEM/IREATING Date Receipt#
Z+ NOTICE
CE
N
0 NOTICE TO APPLICANT:if,ager making this Certificate of Exemption,you should NEW RESIDENTIAL PWB. SQ.FT. TOTAL:
14 become subject o the Workers Compensation previsions of the Labor Code,you must
forthwith Comply with such provisions or this permit shall he deemed revoked. BUILDING FEE
W [� CONSTRUCTION LENDING AGENCY SEISMIC FEE
ItTOO
1 hereby affirm that them is a cmtstruction lending agency for the performance of
O TOTAL: ELECTRIC FEE
the work for which this permit is issued(Sec.309],Civ.O)
Lender's Name PLUMBING FEE
O E-� Lender's Address a QTY. MECHANICAL PERMIT FEE
LU1 cenlfy that 1 have read this applicat th the above information is MECHANICAL FEE
a correct.I agree to comply with all city n conn sIn es and state laws relating to PERMIT ISSUANCE
Ln buildingcanstruction,andh by man sof thiscitymenteruponthe CQNSTRUC IONTAX
U z abovo-memioned Props f ri o re ALTER OR ADD TO MECH.
(We)agree to e,' d ep sea less the City of Cupertino against
liabdities,judgme ,c w ' may in any way accrue against said City AIR HANDLING UNIT(TO 10.000CFM)
in consequence t g s mot,
p� AIR HANDLING UNIT(OVER IO,fNlll CPM)
Tof AppIicauVCpmrcmr ate ( EXHAUST HOOD OVIDUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dam Receipt
Willthe applicant or future building occupant ame or handle hazardous notterbil HEATING UNIT(OVER 100,(X10 BTU) T
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
ael
Code.Semon25532on?
❑Yes ❑No I VENTILATION PAN(SINGLE RPSID)
ISSUANCE DATE
Will iheapplicantarfuturebuildingoccupantuseequipmenrordeviceswhichemit BOILER-COME L3HP OR 100,000 BTU)
hereunder air contaminams as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
District?
Cl Yes ❑No NEW RESIDENTIAL MECH. SQ.PT. PAI I have read the humorous materials requirements under Chapter 6.95 of the ^ I D
if the
building
Health&Safety Code,Sections 25505,25533=it 25S34.1understand that
mcupouildingdoesnot
mentscurrently which must
be,thato is my responsibility Campeauthe 111�I Q�
occupant y.the requirements which must be mu prior to issuance of a Certificate of V�/1®
Occupancy. 5,15
Owner or authorized agent Date O IC9BBU
OFFICE