20963 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address:
neva a one: - p
;I%�r�•- j�l-Iw E-Li 1�1lo 5 -_ 1-- CITY OF CUPERTINQRUILDING DIVISION Q/,/e,1
nsranora Name: - Lie.No: APPLICATION /PERMIT
° /
JM�. yAg 3/z;?zk BUILDING-Q ECTRICAL-PLUMBINCMECRANICAL CATEGORY CONTROL IYblq
Architect/En neer: Lie.No:
—1
-, SA SQTY ELECPRIC,PERMIT, FEE
BUILDING PERMIT INFO, .
'�g0 i�N
Addreec 1<i11TGPOWTISSUANCE
LICENSED CONTRACFOR'S DECLARATION
Ihereby affirm that l am licensed under power.rs of Chapter 9(rommenc APPLIANCES-RESIDENTIALJOB DFSC ON
Ingwlth Sedtan7000)o(Dlvislon3ofthe Ouslnessand ProfealonaCode,and my
Ilcenu b in rce n fect. PANELS
Llrense Cbeaf" a=�41fe" 3/2 7!8/ w `--
Date//9/ ntnaor d,��l�A�arrY _
pM41I e4 DECLARATION MI-l"AMPS -
SQ.FT.FLOOR AREA
a7. nde to my a0 be used as public records. OVER 1000 AMPS � E/SQ.Ff.
OO J
�j LI nse ro(essiona SIGNS ELECTRICAL V I 1"C.- 1
11 DI OWNER-BUILDER DECLARATION SI'P.CIALC / /' / Q .v
2f, 4 (hereby affirm thatI am exempt from the Contractor's License law for the `1.30 �� e/ 1
O following reason.(Section 7031.5,Business a ad Professions Code:Any city or _ 1
FBF' county which requlm a permit to comtmct,alteq improve,demolish,or repair QR E S
4�e any struttum prior to its Issuance,also requires the appBant for such permit to ppfyERD
�`r{ file a signed statement that he is licensed pursuant to the provident of the
3a' Contractor'sLicense Law(Chapter 9(commencing with Section 7000)ofDwi-
m�Og sion3ofthe Butl essand ProfemiomCode)orthat hebexemptthercfromand SWIMMING GTRIC VALUATION
6 the basis for the alleged exemption. Any violation of Section 7001.5 by any OUTLETSSWITCHESFIA7URES
apphemt for a permit subjects the applicant to a civil penalty of net more than V Q�
five hundred dollam($500). NEW RESIDENIIALELECTR__SQ.F1'. STORIES .7 I F,CONSTRUCTION'
[:]I,as owner of the property,or my employees with wages as their sole —
compensation,willdotheworkandthestruturebnotintendedorof(eredfor
sale(Sec.7044,Business and Professloro Code:The Contracture License Law
$� does not apply to an owner of property who Wilds or improves thereon,and OCC.GROUP ' RIS.UNITS
who does such work himself orthrough his own employees,provided that such 3 3
Improvements are not intended proffered forsele.If,hcweveq thebuilding or TOTAL: a
19
Improvement s sold within oneycarofcompletion,the owner-builder will have
�n enol proving that he did not build or bnprove for purpose of sale.). QTY; '•� ;PLUM „FEE'131NGPE1ZNift ti' FLOODZONE APN
Q_9I,L as or of the property,am exclusively ronlradlng wllh Ilce— PERMIT ISSUANCE
nuactors to construct the project(See.70K Business and Profeniom Code: �(�' '
The Comragor's License law does net apply to an owner of property who
Wilds or Improves thereon,and who contracts for such p(ojeRs with a ALTER-DRAIN&VENT.WATER(EA) ,
�gN(actor(s)Bconsed pursunattothe Contractor''s License Law. i . FEE SUMMARY,
LII am exempt under See. B &P C for this reason BACKFLOW PROTECT.DEVICE OUTSI DE FEES
.d'
: Owner Date
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N'r - •
WORKMAN COMPENSATION DECLARATION RECEBTN
re FIXTURES PER TRAP SCHOOL TAX Y N
• rufl rcby affimkcr that 1 have•certificate of consent to mal the or RECEIPT M
3800,ataof Workers Compematlon Wuanceora rertilled ropy themof(Sec.LabQ OAS EA SYSTEM-1 NCA OUTLETS PARK IEE Y N
Policy GAS-EA.SY5—) OVER DING DIN
' Com any - � BUILDING DI VISION IT ES
ffCertBled copy Is hereby famished. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
MCnnified copy s filed with the city Inspection division. /'
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRM' PAID Q/7 G7 /
COMPENSATION INSURANCE g, `Date RCCCI t#
(Thlssectlan need not W completed Bite permit slor one hundred dollars
(s1W)orless.) ENERGY FEE Y N
I certlfylhat in the performance otthe work forwhlch this permit Is Issued, —
I shall not employ any person in any rnanner so as to bemire subject to the r.�� ^ C
Workers'Compensation lawsol California.Date - PAID Jyl`10- J 761
Q Z NOTIAppliCE
Date Recei tit 47,
OCI
ZO shouNOTldbco APPLICANT:If,after making Compensation
procate ofe.ofteLyou -
F
CW e,
yoemmesubjcnmthe Workers'CompevaHonprovhis per it s Labbe TO
W Code,you most(onhwith comply with each provisions or this permit shall be ��•3 IN ••E
10
deemed revoked
W — CONSTRUCTION LENDING AGENCY EIS C EE •�
Il 1herebyaffirmthal there s a construction lendingagency forthe penorrry I I, rr--1Iq
Zanmo/theworkforwMchthspermitsluued(Sec.3097,12N.C.) TOTAL: 3(L
(> O Lender'.Name - - P •E -
LL Leeders Address QTY. MECHANICAL PERMIT FEE IME !MNIC • 'B
IcerUfythatlhavemadthsapplicationandgatethattheaboveinformationO aIs correct.I agree to comply with ail city and counlyordlnancesand gate laws PERMIT ISSUANCE - 1-4.aD:
relating to building construction,and hereby authorize repre:ntatives olthisZ ity to enter uponthe above�mentioned property for Wpection purposes. ALTERORADDTOMFGH. R el t#
V — (We)agree to save,Indemnify an d keep harMeas the City of Cupertino Pagainsth lee,J,rd n , and xpensaswhlchmaylnanywayxmrae AIR HANDLMG UNIT(TO 10,00 CFM) SUBgainst- ity i of t gmantlngofthepermit -AIR HANDfING UNTT(OVER IO,fA0CFM) UCf70N AX
I atum ofA pacant/Contractor Date EXHAUST HODD(W/DUCT) UCTION XPAID:HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant store or handle hxzardaus I'[EATING UNIT(TO 100,000 BN) RCc
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the -
Ilealthand Safety CodeSection 25532(a)7 - FIP.ATING UNIT(OVER 100,000 BTU) TOTAL: lf544
0 Yes , ILa,,�J No -
_Mill the appldant ortutum building occupant rtes equipment or devices VENTILATION rAN(SINGLE RFSIO) I��x7CE DATE
which emit hazardous air contaminants as defined by the Bay Arca AU
aF v Quality Management D❑istrict? - BOILER-COMP DHP OR 100,000 BTU) v
4 Yea N No ^ q�
�tl have read the haza us matenas requirements underChapter 6.95 of BOILER-COMP(OVER 100,000 BTU) MAR RYa (1 1Qgt
the California Health&Safety Code,Sections 25505,25.5]3 and 25534. I e uX I
'`1'71 understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FF..
re poreibility to notify the occupant of the requirements which most W met �.r Of
'prior to issuaW fica
nce a Ce" te ofoocutgary. IZ c15Y Qw� `Ar
Owner or authonced agent - Dole -1
TOTAL: L p,a g55UED BY:
OFFICE COPY I