20571 (2) APPLICANT TO FILC'IN INFORMATION WITHIN RED LINES — USE BALL POINT'PEN ONLY
Building Project Identification PERhBT NO.
Oulldiag Address: ) ' 20571
�O r a�
i ( 6 4 � r G l I
wnera N area:, A/ one: A
-5 /y ' 253 r 9s CITY OP CUPERTINO-BUILDING DIVISION
centradm',Name' LI<. APPLICATION / PERMIT
�. CCLIF~ BUILDING-ELECTRICAL PLIIMBINC•MECHANICAL CATEGORY CONTROL
LOS-7
Architect/lingln r. k.No:
C
QTY 'ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: '/O J h 7 Ce PERMIT ISSUANCE 1sQ3 LbL1 PLUMB
❑ " ❑
LICENSED CONTRACTORS DECLARATION }I�f
I hereby affirm that l am licensed under provisions ofChapterg(commenc. APPLIANCES-
RESIDENTIAL JOB DESCRIPTIONirgwRh Sedk n7000)of Dlvislon3 ofthe Buuinnsand ProfesslonsCode,and my
It List- Is In full(o and effect. - PANELS ^ - -
Liansc lam <S Lmr dor Y
Date` enmtter �4 Z\� C
ARCHITECI`SDECLARA ION. 201.1000 AMPS
az I uv m la s 00 used u r�yBc records OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FI.
E `� Licensed Protesslo SIGNSELECTRICAL
`c of OWNER-BUILDER DECLARATION SPECIALCRKUIT/MLSC
Z"�Z Iherebyafl—thatlamex.reptfromtheComractor.LieenssLawfarthe
pO following reason.Gectlon7031Z,Businessand Professions Code:Any cityor
FZ F. TEMP.MEM OR POLE INST.
In countywhich kmt.IspertNtmronstmgaltep)mpmve,dennWh,ormit to
O ..� any aWcturcpateneft that hecgako sed Pursuant t the rovisihpermite POWER DEVICES 1
� (Ile a signed statement that he k licensed pursuant to the proWlons of the
3
Ob; Contractors License Law(Chapter 9(mm
meM
ngwithSection7DOO)ofDivl-
skm3 ofthe Business and ProfessionsCode)orthat he b exempt therefromand SWIMMING IDOL ELECTRIC VALUATION
'S the basis for the alleged exemption. Any violation of Sealon 7031.5 by anyC_z` V
N D
applicant for a permit submm
jectsthe applicant to a civil penaltyofectothan OUTLETSSWHCHESFTICNRES al JL/
fiveama dollars ro
'9..' [31,1,I,Gas owner of thehe property,
property,or my employees with wages AS their sale NEW RESIDENTIAL ELFLTR Slj: . STORIES TYPE CONSTRUCTION
Qcompensation,wllldothe work andlhe structure is not intended or offered for
O sale(See 7001,Business and Professions Code:The Contactors License Law
does not apply to an owner of property who builds or improves thereon,and /AvDGG.
who doeasuchwmi,himself or through his own employees,provided that such CROUP RFS.UN175
Improvements are not intended oruffered forsale.If,however,thebuilding ort7fp)„ ,
Improvement isaold withinomrarofcomplmiomtheowner-bullderwlll have L
tlirjureenofproving that he did not build orimprove for purpose ofukJ. QTy, PU90BI&PERAW FEE F1OOD7DNE APN
Lf L as owner of the property,am exclusively mntraRlng with licensed PLIZMIT I C
contractors to ronstrud the project(Sec.7074,Business and Professlaru Code:
The Contrador's License Law don not apply to an owner of property who IT
ALTER-DRAIN -WA
builds or Improves thereon,and who contmttl for such pkajecre with a ,
ryu(�a&or(,)licensed pursuant to the Contractor's License Law. BACK FLOWT.D FEE SUMMARY
Lf I am exempt under Sec. B 6 P C for this mason
D S OOA, ND. SANITARY Y N_�
Owner Date _ RECEDrfp
A--R
WORKMAN COMPENSATION DECLARATION S SCIIOGLTA% Y_ N_
,ceLMa hereby affirm that I have o l rt nn of consent to apytheure,or a
sateof Workeri Compensauonlnsurance oa certified ropy thereof(Sec. RFDE
3800,Isis C3 ^ �j/ f GAS .1 WG10 EFS N PARK FEE Y N
Palley p_ — RECERT M
GAS .SY OL'ER4
Cam ansa Ca / / b )
�_IGI BUILDING DIVISION FEES
Ca copy Is hereby lurnlshed. GREASR/INDU INTERCEPTOR LA
PNCHECK FEE �� b
Certified copy Is filed with the city inspection division.
CERTIFICATE OF EKEMPFION FROM WORKERS' GREASE TRAP PAID sea beCOMP
SEWER-SANITARYSTORM EA 200FR Date Re i t#
(This lection need fiat be completed If the permit V for one hundred dollars '
($100)rtifyt i WATER HEATER W/VFNF/ELECTR ENERGY FEE Y N
Ill not that In the person In an the wale an as to
this pesubjedrmit I.to the
1 shall not employ any Person In any manner so u to berome subject to the WATER SYSTEM/TREATING ..
Worked Compenutlon Laws of Ca8(ornk. Date PAID
O—Z Applicant Date Remi t#
Z 0 NO TICE TO APPLICANT:IL aNer making this Certltlum of Exemption,you NE7V RESIDFNITAL PLMB. SQFf.
•F should becomesub)ect mthe Workera'Compensation provisions ofthe Labor TOTAL:
W Ccde,you must forthwith comply withsuch provblonsor this permit shall be U N •'E 0
decreed revoked.
LU
mCONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there b a constmcilon lending agency for the perform ELECTRIC FEE
D Z arca ofthe work for which this permit is Lwred(Sec.3097,CIv.C.) - TOTAL:
02 Lender's Name - PLUMBING FEE
ly.l— Lender'.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertlfythatlhavc read this appRatlonand patethattheabovelnformatlon
lacomnC.i agreeto comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} M relating to building construction,and hereby authorise representatives alibis
1— N city to enter upon the above-mentioned property for Inspection purposes, ALTERORADDTOMEAH.
Z (We)agme to save,Indecent fy'an d keep harmless the City of Cu perlino Date Recei t#
V against 11 tles,pdgments,costund n, uses which may in anywayaccrue AIRHANDIINGUNIT(FOI0,000CFM) SUBTOTAL:
.gal I City In cense,) of the °Ung of this permit AIR HANDLING UNIT(OVER 10,000CEM) CONSTRUCTION TAX
Signature ofA ant Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA2ARDO US MATERIALS DISCLOSURE
Wllltheappilca at orfuturebuilding occupant store or handle hazardous 'HEATING UNIT(TO 100,000 BTU) Date - Reeei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the
Flcalthand Safety Code Se ion25532(a)7 HEATING UNIT(OVER 100,000 BTO) TOTAL:
Fly. I!No
Will the applicant or futurebuilding occupant use equipment ordevices VENIIATION 17AN(SINGLE RESID) I$�DANCE DATE
which emit harurdous air contamlnsnt.as defined by the Bay Area Air Pp�4i U
Quality Management District? BOILER-COMP OE0s OR 100,0(3 BTU)
I Yes Fl No -
have mad fealthhe Safet mode,le tionsZmrntsundernd 255346.95 of BOILER-COMP(OVER 100,000 BTU) J1jIq 2 `) 1"' u
the Griper°la Hcfth k Safety Code,Sections 75505,have
a t and,that i 7
understand that ifhe heoccupant
cgdoes not .require area tenant,that UUmy NEW RE4DFNDAL MECIi. SQ.f4
reser to issuance
nal(ytheaeate an toftherequlrcmenta which must be mel a, fa .a '
' prior to Issuance ofd Certitlatc ofOttvpanry. � Ql�lt @� (RIIq!'f�lna'. .s
Owneror aothorlud agent
Data ISSIIEDBY: I\�o-'�"7- lT'4'1"11`aA)
TOTAL'
OFFICE COPY