20181 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERM NO.
Building cle 13lossom itle 20181
wnera me.
L ehso 2V CITY OF CUPERTINO-BUILDING DIVISION
ContraGoi Name: Lie. APPLICATION /PERMIT b �
BUILDING-ELECTRICALPLUMBING-MECHAMCAL CATEGORY CO �/
Architect/Engineer. Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFOZ
Address: PERMITISSUANCE (�71 19 ❑ ❑
LICENSED CONTRACTOR'SDECnsof Ch ON
Ihereb f(Irtn lhatlam B<enud under rovlsions of Ga r9(mmmenc MPLIANCESRESIDENTUL
ya p ate JOB DESCRB''1'ION
'ngweh In
7000).!d cited.
Busincuand Profeeslone Code,and my ,� �������` –
license is In s forco and d.# PANELS Irr rTl'nG—
License Claes Uc.N
Date Contractor UP TO 200 ANTS
2011000 AMPS
ARCHITECT'S DECLARATION
O] (understand my plansnhaB be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA E/�.ET.
rresu OSIGNS ELECTRICAL
L� Licensed Professional
�¢ OWNEReBUILDER DECLARATION SPECIAL CUtCUIT/MISC Y �
L, Thereby afllrmthat OWNE -BUILDERxempt the DECLARATION
License Law for the L lJ
y following residua.(Section 7011.5,Business and Profeulors Code:Any city or SMP.METER OR POLE INS(.
cauntywhlchrequlrnapert ttowmtmc4alter,4npmve,dennlbh,ormpalr
anystm=mprlortolts Lswance,al mrequl theappBcantfwsuchperMtto )OWER DEVICES
K (� file a signed Gatemen that he l9 licensed pursuant to the provlelons of the
04 Contractor's License Law(Chapter 9(mnuriencing with Section 7000)of Divi- VALUPTION
30�^ sion 3 of the Business and Professions Code)or that be is exempt therefrom and SWAIMING POOL EL C
S the basis for the alleged exemption. Any violation of Sort km 7031.S by any OUTLETSSWITCHESFI ES r W Q O
<e applicant for a permit subjects the applicant to a civil penalty of not more than L
fi hu red dolWa($500). IN
NEW R DENTIAL EL TR SQ.FT. STORIES TYPE CONSIRIICTION'
as owner of the properly,or my employee with wages as their sole
k76 satmn,wuldu the work and thestmcture lance intended or offeredfrr
$ O vie lye.7014.Bwbless and Pmf.Jmm Code:The Cont.eftes Licerue Taw
does not apply to an owner of property who builds or improve thereon,and
$^ whodoea suchwork himselforthrough hisownemployero,provided that such OCG GROUT' RFS.UNITS
Improvements are not intended proffered for sale.If,however,the building or TOTAL: VS ua
Improvement a sold within oneyearofcompletlon,the owner-builder will have
t den of proving that he did not bund or improve for purpose ofsa@J. QTy. BI P IT FEE FLOOD ZONE APN
UI,as owner of the property,am exclusively com—Ing with nornsed PERM ONCE
contractors to construct the project(Sec.7064,Business and Profeulou Ccsdv
TheContractor's Wmnx Taw does not apply to an owner of property w o AL /N& - TER
bullds or Improves thereon, and who contracts for such Objects with FEE SUMMARY
,n➢BIf(ador(s)licensed pursuant to the Contractor's Llcenx Law, gA IN T .DE CE
u 1 am exempt under Sec. B &P C for this recon
SANITARY Y_ N_
Owner Date NS F RECEU'TN
WORKMAN COMPENSATION DECLARATION &7-4
11RES I'ER TRAP SCHOOL TAX Y_ N_
QI hereby affirm that I terve a certificate of consent to xB-Inwrc,ora RECE FT N
certificate ofWorkera Compensation Insurance or a certified copy thereof(Sec. FA,S - 40Ull B PARK FEE Y_ N_
3800,Lab CJ
RECEIl N
Policy N CAS FA.SYSTEM-0VER d(FA)
Com BUILDING DI VISION FEES
any
Com
copy is hereby famished. GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
MCertifled copy Is f0d ewith the city inspection division. (rya-J Q�
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANCfARY-STORM E.A.200FI. Date RCCCI I# �
(Thissection needrot becompleted tithe permit bforonehundred dollars L
(SIW)or less') WATER HEATER w/VEM/ELF.CTR ENERGYFEE Y_ N_
I cartify that in the performance of the work forwhich this permit is Ended,
I shall not employ any person In any manner sou to become subject to the WATER SYSTEM/TREATING
Worker'Compensation laws of California.Date PAID
O Applicant Date Recei t#
2 NEW RESIDENTIAL PLMB. SQ.FT.
Z O NOTICEca a APPLICANT:a Worfterkers'
makinrs'Co perhis ation catepro is Exemption,you
should become subjectmthe Wprken'Compensatlon provisions ofthe Labor � TOTAL:
I– N Code,you must forthwith comply with such provisions orthis permit shall be BUILDING EE
j deemed revoked.LU — CONSTRUCTION LENDING AGENCY SEISMIC FEE
C e Iherebyaffirm that there is a commaction lendingagency forthe perfornF TOTAL: ELECTRIC FEE rs�
Z ance ofine workforwnichlhis permit is Issued(Sec.3099,Clv.C.) PLUMBING FEE
(� O Lender:Name
LL Lender's Address QTY. MECHANICAL PERMIT FEE
O W Icertlfythatl have read this application and Gate thatthe above Information MECHANICAL FEE
a Iscormet.Iagree to comply with all city and county ordinances and Gate laws PFRMTTISSUANCE FEES PAID:
W relating to building construction,and herebx
yauthomeareprentativesofthb
Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
(We)agree to save,indemnify an d keep harmless the City of Cu pertbw Date Reecipt#
V against lhbl tles,pdg..t., Gaandexpensnwhlch msyinanywayaccroe AIR HANDLING UNIT GO 10,000 CFM) SUBTOTAL:
against sal Ity In conseque of the gran'ng fthls pe) it.
AIR HANDLING UNIT(OVER 10,(100 CFM) CONSTRUCTION TAX
g arc of Appuca /O�nractor Date - IXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
F' lARDOUS MATERIALS DISCLOSURE
Will the appli rat or(uture building occupant store or handle havr ou� HEATING UNIT(TO 100,000 BTU) Date RCCCipf#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
1lealth and Safety Cade ion 25532(a" HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes o
Willlheapplicant euro building ompant use equipment or devices VEND LATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haradou air contamimnb as defined by the Bay Area Air
Quality Mawgemcnt 'td BOILER-COMP(3FNQR100,o0o BTU)
Yu LLII''YY��
have read the hazy pus nuteriaIs-
s requirements under Chapter 6.95 of BORER-COMp(OVER ID0,000 BTU)
the CallfornhaHcalth Safety Cols asoripns25505,25533 and 25534. IfIPR k q 1990
understand that if the building does not currently have a tenant,that It is my NEWRESIDENTIALMECH. SQ.FT.
responsibility to notify the oma nt of the requirements which must be met
prior to as pof a Certificate Ottvpa
autherired ent Date J TOTAL: ISSUED BY: """'— II'*�"
OFFICE COPY