24201APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY,
Building Project Identification
PLR.WTNg
causing Aeane.d:
Z� �ZC
4 2 01
wners Name: Prone:
S � 6�L�46
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
RMDINGELECTRICALML BINGMF MCAL
CATES'.ORY
CD.tmnD.. r : Lie. No:
rehitect/Engineer. Lk. No:
QTY ', ELECTRIC P RMIT - FEE
BUILDING PERMIT INFO
Address:
1 PERMITISSLANCE: ^��
❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provision. ofChapter9(mmmmc
IngMth5 ton7000)of DsAsion3ofthe Buslnessand ProfedalonsCode, and my
limn. I. in fail to. and eff ns.
License Class
APPLIANCES.RtSIrENTIAL
.� JOB DFSCRII'170N
PANELS
Date Contractor
C.mr
�"� �,/
proo,
2 000 AMPS
ARCHITECTS DECLARATION
I understand my pl... hallbeased as publicrcmrds
Limned Professional
IWO AMR'
SQ/ FT. FLOC) ,A#EA S/SO. Fr
V
SIGNS FL C
/MLSC
OWNER -BUILDER DECLARATIONSPECL
I hembyaffir n that I am exempt from the Contractors License LaAtyt
TIM M OR E INST.
following reason. (Session 7031.5, Business and Profession. Code: An
county which requires a permit to contract, alter, improve, demolish, or repair
any structure prior to its Issuance, also requires the applicant for such permit to
file a signed statement that he Is limned pursuant to the provision of the
Contractor'sLicense Law (Chapter 9 (commencing with Section 7000) of Divi-
sion3 of the Business and Prdeaslon Code) orthat he is exempt therefrom and
the balls for the alleged exemption. Any violation of Session 70)15 by any
apphcant for a permit subjectsthe applicant to a civil penalty ed net more than
pQWggD
"",;/C; POOL ELECTRIC
OUTLETSSW[TCI-IPSFIX'FURFS
VALUATIOIN,
2� 1 \
NEW RESIDENTIAL ELECTR SQ.FR
five hundred dollanhepr.
❑ as owner, of the property, or my employees with wages their dote
STORIES
TYPE CONST RUCTION
e
compensation, willdothe workand the r
Intended or offered for
744, Code:Tbnot
sale (Sec appy Business and Profession Code: The Llcene Law
-
does whodoessuch torn owner ofproperty or finpctols
rough who nempoyees,pvpted that and
whodoesauchwork hlmseQorthwgh his ownemployeeq provided that such
OCC.CROUP
RFS UNITS
improvementsare notlatended oroffered forsale. If,howevegthebuildingor
Improvement ls wld withln oneyearofcompletdon, the owner-bullderwill have
T !
it en of proving that he did not build or Improve for purpose of sale.).
d owner of the property, am exclusively contracting with licensed
contractors to contract the pmject (Sce4y 70Business and Profession Code:
QTY. PLUMBING PER MIT FEE
t c
PERMIT ISSUANCE'
FIpp WNNE
Al
The Contractor'. License Law doe. net apply to an owner of property who
Wilds or Improves thereon, and who contracts for such ptojects with aVNA
,LLt(ctor(dI licensed pursuant to the Contractor's Llcenx Law,
U I am e...pe under Sec B & P C for this reason
BACK p ,D' fl
FEE SUMMARY
pRAI )L -
FD(TURGS PER TRAPr ATr 2i4�
C i UTLM
NITARY Y N
RDCEIPp tl
Owner Date
WORKMAN COMPENSATION DECLARATION
Ell hereby affirm that I have a mrtlfleate of consent to m0 -Insure, or
certificate D(Workerc'Compenation Insurance or a certified copythereof(Sec.
moo, Lab C.)
300E TAX Y N
REC NX
PARK ITP Y N
Policy tl
REA= N
GAS EA. SYS!'EM-0VER d (FA)
Co ny
BUILDING DIVISION FEES
ertified copy b herebyth the city
Cealfted copy is filedhere with the sty inspection division,
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE 7f�
_l
GRP -ASE TRAP
CERTIFICATE OF EXEMPTION FROM WORK ER S'
PAID
SEWER -SANITARY -STORM EA. 2f10FT.
COMPENSATION INSURANCE
(fhissectlonered notbecomplemMtb
d iftheperfor amhundreddollars
Date Recet
($100)orless3
(certify thattsthe performance ofthe wok(orwN<h this permit is leased,
I shall not employ any person In any manner so as to become subject to the
Workem'Compen tton Umof California. Date
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y —
PAID
WATER SY5177.T/TREATING
Applicant
NOTICE TO APPLICANT-. If, siker making this Certlficete o(FxempOon, you
should became subject to the Worker'Compereation provision of the Labor
Code, you must forthwith comply with such provlslon or this permit shall be
deemed revoked.
Date Recei t#
NEW RESIDENTIAL PLMB.SQ.FT.
TOTAL:
BUILDING _ Ct
CONSTRUCTION LENDING AGENCY
SEISMIC FEE {{
Ihereleya(firm that there Is a conetruction lending agency for the perforrry
anof the work for which this permit is Issued (Sec. 3097, Civ. CJ
TOTAL:
ELECTRIC FEE
QTY. MECHANICAL PERMIT ` FEE
PLUMBING FEE
L.ender'd Name
Leadee.Address
I certify that I have read thisapplication and state that the above mf don
b mrrcct. lagreDto complywith allcityand muntyordinanoesanddta1.laws
MECHANICAL FEE r
PERMIT ISSUANCE i/
FEES PAID:
relating to building contruction, and hereby authorize reprexnlativn of thls
city to enter u Pon theaWvcmentioned property for Wpectlon purpossa.
(We) agree to save, Indemnify an d keep harmless the City of Cu pert Ino
ag.iet liabilities, Ju rats,",.ad expenses which may In any way accrue
against,.c... equence .grant of thlspormit.
-
ALTER OR ADD TO MECH.
19
DatC Recei I#
P
AIR HANDLING UNIT(TO 10,000 CFM)
SUBTOTAL:
AIR HANDMNG UNIT(OVER 10,000CFsU
CONSTRUCTION TAX
nature ofppllo Cont ctor Date
F7(HAUST HOOD(W/DICT)
CONSTRUCTION TAX PAID:
2ARDOUS MATERIALS DISCLOSU E
HEATING UNIT (TO 100,000 BTU)
Will capp ratorfuturc building occupant Blore or handle hazardous
material ad defined by the Cupertino Municipal Cade, Chapter 9.I$ and the
Date Recei f#
HEATING UNIT (OVER 100,000 BTU)
TOTA . C.
Health and Safety Code Session 25532(a)2
F-1YesM No
VENTILATION FAN (SINGLE MID)
ISSUANCE DATE
Will the applicant or future building occupant use equipment or devices
which emit hazardous air eontaminnts as defined by the Bay Area Air
BOILER -COMP OHPOR 100,0010 BTU -
Quality Management DleMct7
Yes❑ No
have need the hazardous materials requirements under Chapter 6.95 of
the California I lealth & Safety Code, Section 25505, 25533 and 25534. I
understand that if the building does not currently have a tenant, that It is my
p
aa9 p
L
S�A1
BOILER -COMP (OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ.FI
r ponibllitytonollfytheoccupantoflherequlrementswhichmust6e.t
prior to Issuance of a Certificate of0coupancy.
i/'is/
01 a7.�YG(/ V/'v
ISSUED BY: r s •—/
Ownerorauthorlmd agent Date
OFFICE COPY