20251 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address:
20251
lo�1t o
W4'kk rQ Z -ea e�3 CITYOFCUPERTINO-BUILDING DIVISION
C tractor's Nam: LI,.Nce APPLICATION /PERMIT
Owe a�C ?61255101 BUILDING-ELECTRICA4PLUMBING-MMLAMCAL CATEGORY CONTROL
Arcldtect/Englaeer. Lie.Na:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. SLUG FLU�l
PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby
ectioInnthat lamllcenxfthe under BuprwWomo(Cestora9(le,and c APPLIANCFSRESIDENI'fAL JOB DFSCRUPTION
Ingwe is in Fon 7000)o(force anDlvfect. o(the8uainesand Pre(esdonaCode,and my
license b In fuB force and effect, PANELS
I.Icenx Class I[.N UP TO 2DO AhILS
Date Contactor 201-1000 AMIa5 _ ` \` ` \N
ARCHIT be us DECLARATION OVER 1000 AMPS $Q,F[,FLOOR AREA f/SQ.FL
7 I understand my plan nhaU be used a public records
u�O
U� Licensed Professional SIGNS ELECTRICAL
Q 41 OWNER-BUILDER DECLARATION
En Fn SPECIAL CIRCNT/MLSC
Thereby affirm hailare exemptfromthe Contraaorb License Gwfor the
0 9 following reason.(Section 70315,Business and Professions Code:My city or TEMP METER OR POLE INSP.
F �"' county which requires a permit to construct,alter,improve,demolish,or repair
any structure prior to its Issuance,also requires the applicant for such permit to
r� file a signed statement that he k licensed pursuant to the provisions of the POWER DEVICES
Contractors LtmWo lzw(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
F,�Os sion3 ofthe Buainessand ProfnalonsCode)orthat he to exempt therefromand VALUATION
S°•-t the bash far the alleged exemption. Any violation of Section 7031.5 by any
Q OUILE7SSWITCHESFIXCURFS \.J llJl
��� applicantfora permibubjectstheappllcant too tivll penalty o(nat nnretlun ��
Ove hundred della.Matti.
NEW RESIDENTi ELECTR SQ.IT. STORIES TYIaE COF:SIRUCTION
(n ❑I,as owner of the property,or my employees with wages as their sok
C compensation,will do the work,and the structure Is firs intended or offered for
5 O
.in(Sec.7044,Business and Pm/emios Cade:The Contraome.Lim.Law
$ does nor apply to an owner of property who builds or improve thereon,and
who does such work himself or through hisown employees,provided that Such OCC.GROUP RFS.UNITS
Improvements are not Intended mattered forage.If,however,thebullding or TOTAL:
Improvement0s idwithlnoneyearofcompletb theowner-bu0derwilllove
th,¢rrden of proving that M did notbuildorimproveforpurposeofuk.). QTY. PLUMBING PERMIT FEE
LJ L as owner of the roe FIADD]DME APN
property,jed Se exclusively Business
and Professions
pECMIT ISSUANCE
contracto.to roraW ct the project(Sec.7044 Business and Proles loris Code:
The Contender's License Law does fiat apply to an owner of property who ALTER-DRAIN k VENT'-WATER(EA)
bu0ds or Improve,thereon,and who contracts far such pWiects with a FEE SUMMARY
yyttffactar(s)Ilcenxd pursuant to the Contactor'.License Law. BACK FLOW PROTECT.DEVICE
c LI I am exempt under Sec B be P C for this reason
OUTSIDL FEES
DRAINS FLOOR,ROOF,AREA,GOND. SANITARY Y_ N_
w
• Oner Date RECEBT N
WORKMAN COMPENSATION DECLARATION
[31FIXTURES PER TRAP SCHOOLTAK Y_ N_
1 hereby affirm I haw acertificate have a rti0cate of consent to self-Inmare,ora RECEIPT N
certificate of Werke.'Compensation lnsurimm ora certified copy thereo(LSce. GAS PA.SYSTEM-1 INCAOUILETS PARK FIT.. Y N
3800,lab CJ i--
PoliEavr cy olicy N CAS F.A.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
Com any
�Certlfued copy b hereby famished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy is filed with the city impection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date Recei t#
(fhissection need not be completed tithe permit Is forone hundred dollars
(BIOD>mlea.) ENERGY FEE Y— N
1¢rtilyth lheperformanceoftheworkforwh thio and la LIN, WATFRHEATI]2W/VENT/ELECTR —
I shall note 1 any perm In any manner so to he WATI]t SYSTEM/TREATING
Workers'C. .ait .Law.c if°cola.Date I�1 PAID
0If
2 Applica"! L-' NEWRESIDENTIALPLMB. SQ.FT. Date Remi t#
Z O NOTICETOAPPLICA U, a dngthb CerBfcam.f Exemption,you
shwid become subRct l t e ` n'Compematbn provisloe o(the Labor TOTAL:
F W Code,you must(orthwB reply with such provisions;or this permit shall be BUILDING " l
W ] deemed revoked. -
n. c CONSat TRUCTION as LENDING AGENCY SEISMIC FEE L
I hereby affirm
orkfo whicht is permit a Issued(Seion n.3097, iv.C.)¢perform TOTAL ELECTRIC FEE
D OZ afire of the work(orwhlchthts permit VLssued(Sec.3097,Civ.C.)
Lender.Name PLUMBING FEE
LL 1- Lenders Addrea QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U Icertilythat l have read thkappilcation and state that the above information
O W Ise.rren.I.Sme to comply with all dtyand roumymdinan¢sand stale laws PERMIT ISSUANCE FEES PAID:
>. M retail ag to building corstruation,and hereby authorize representatives of this
H Z city to enter upon the abovo-men(ioned property for Wpection purposes. ALTERORADDTOMECH.
_ Date Receipt#
(We)agree to save,Indemnity and keep harendesswhich the City of Cupertino AIR HANDLING UNIT(TO 10,0D0 CFM)
V agaWtllabilltles,pdgmenb,coes and expenxawhlch may In any wayamue SUBTOTAL:
against Said City In consequence of the gram Ing of this permit.
AIR HANDLING UNIT(OVER IO,000CFM) CONSTRUCTION TAX
Sig®mm of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a pplicant or future ba thing occupant store or ha ad In hazardous HEATING UNIT(TO 100,000 BTU) Date Recel 1#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Cede Section 2SS32(a)2 HEATING UNIT(OVER 100,000 BTU) TOTAL:
rlYes No
WIII heappliant o�ture building aam pant use equipment ardevices VENTILATION FAN(SINGLE RESID) ISSUANCES DATE
which emit hazardous air contaminants as defined by the Bay Area Air
. Quality Management District? BOILER-COMP 0HPOR 100,000 BTU)
Y" "° (9AY U 8 I�Jb J
have read the Nazar ous materials requlrcments under Chapter 6.95 of BOILER-COMP 100,00081LI JA
AYalth k Safety Code,Sections 25505,25533 and 25534. 1
fthebu Bding does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQFT
naily ocapantoftherequirements hie stbc.t City ff CIImfino
o(a nIL toof Occvpanry `zed a t Date
TOTAL: 155IJGDB
OFFICE COPY