20726 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
B.iIdm5 Project Identification PERMIT NO.
Building Address: 207.26
7e-vJeN 0* '/ / i h ,a
vers ame:/ one: p A
rloAlelem Cnk" CITY OF CUPERTINO-BUILDING DIVISION / _
contra Rola Name: -Lic.Nm APPLICATION / PERMIT /a 7
BUILDINGII.EC7RICAGPLUMBING-MECFIAMCAL CATEGORY CONTROL N
Archl ca/Engineer: LIc.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ ftj'Jif ❑ ❑
LICENSED CONTRACTOR'S DECLARATION �_
I hereby affrem that l am licensed under provisions of Chapter9(commune- APPLIANCES-RESIDENTIAL JOB DESCRIPTION
mewl is
fon forcea deffect. (the Businessand Pro(osionaCode,and my
license b e full form and effect. PANELS
Licenseclass /p Lfc.N 3.F(0 47.3
Date/„/—%-Y/7 Contractor !,jZ'1 d 34V iUP To
ARCHITECPS DECLARA ION 201-1000 AMPS
O O I understand my plain shall be used as public records. OVER 1000 AMPS.
SQ.Fr.FLOOR AREA S/SQ.FT.
1edu Licensed Professional SIGNS ELECTRICAL'
w OWNER.BUILDER DECLARATION w . '
fn SPECIAL CItCNT/MLSC ALE D
Iherebyalfirmthat lam exempt fromthe Contractor's License Law for the
7O-- fallowing reason.(5ectlon 7(31-5,Business and Professions Code:Any city or
O G t. IFAIP.METQi OR POLE)NST.
county which requima permit to construct,alter,Improve,dernolish,orrepafr E) UTE
QanystmRure prlortoitsi ance,alsoequimstheappBunt for such permit to POWER DEVICES �A Ft
c.U file a signed statement that he Is 1' pursuant to the provisions of the `Y'
7pp755,�O`„ h At
Contractor's License Law(Ch 9(commencing with Section 7000)of DIv4
^30rec^ sion3ofthe Businessan esslonsCode)orthat hebexem Iherefromand SWIMMING POOL ELECTRIC N
gY the oasts for the aIle exemption. Any Wolation of SMiont 70315 by any 'RE
ya OUTLETS-SWITCHES
"�'O appllcantfora permit subjectstheappllcantto a civil penalty of mat more than 4
m i five hundred dollars(5500).
1 as owner of the property, NEW RESIDENTIAL ELECTR SQFT. STORIES TYPE CONSTRUCTION
❑ , p ork,and
or my employees with wage as there dole
compenaation,willdothe work andthe structure Is not intended or offered for
� n sale(Sec.7044 Business and Pmfessiore he Contractors License Law
does not apply to an owner of property obulldd orimprovn thereon and
p whodoedsuchworkhiraci(Orth Isownemplayen,provided that such
= OCC.GROUP RES.UNITS
improvements are not intends roffercd for sale.If,however,thebuildingor TOTAL: I
i provement bdotd wit rte yearofcompletbn,theowner-bullderwlll have
thq*rden of prov a[he did nm build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
L L as owner of the property,am ex Iusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project . 044 Bushes"and Professions Code:
The Contractor's License U net apply to set owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or Improves thpron, and who contracts for such p(u)es with a FEE SUMMARY
c,0.IIjjanoKs)11¢nsed pumuant to the ContnRora License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec B& P C for this mason
QI]TqfinF Put,;
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N
Owner Dale RECEIPT N
WORKMAN COMPENSATION DECLARATION Fp-ARES PER TRAP SCHOOL TAX Y_ N_
[:]I hereby a(fvm that I have a certificate of consent to del!-Inwm,ora RECEIPT N
certificate of Workers Compensation Insurance or a certRled ropy thereof IS". GAS EA,SYSTEM-1 INCA OUTLETS PARK FEE 'Y N
Saw,Nbc.) YA/ PBoy�eF333 RECEmra
Com any -
CASEA.SYSfEM-OVER401M BUILDING DIVISION FEES
[y�Certified copy b heed wfih to city GR[ASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑
Certified copy b filed with lM my inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE gEyypR-SpMTplyy-SIpRN EA."Fr. Date Rcceipt#
(This section need not be completed If the permit b forome hundred dollars
(51(10)or cad.) WATER HEATER W/VENT/EI.ECTR ENERGY FEE Y N
I.Ai�ICAW..
nceoftheworkforwhichtMspermitisbsued,
I shall noin any manner so as to became subject to the WA777I SYSTEM/TREATING
Workers' of California.Date PAID
O Z Applicant NEW RESIDENDAL PLMB. SQF. Date Remi t#
Z O NOTICE , fter makdng this Certificate of Exemption,you
shouldbecame subject to the Worloms Compensation provisions of the Labor TOTAL:
W Code,you most forthwith comply with such provisions or this permit shall be BUILDING FEE
W ] deemed revoked.
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
M Z I hereby affirm that there lsaconstruction lending agency for the perform ELECTRIC FEE
Z .arm of the work! which fhb perMtblesuetl(sec.309],Civ.CJ TOTAL:
(� O Lender§Name PLUMBING FEE
LL H lender's Address QTY. MECHANICAL PERMIT FE6' MECHANICAL FEE
O W Imitifythatlluver dthbappButlonand statethatthe above Information
wrreR.lagreemcoo with all Rtyand county ordinance and state laws PERMIT ISSUANCE FEES PAID:
>. IL elatingtobullding cons[ otter,and hembyauthorire repmsentaBves ofthts
N city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH.
Z (We)agree to save,mdemmfy an d keep harmless the city of Cu Penton Date Receipt#
O against liabilities,judgments,crostsaed expenses which may in any way sccrue ' AIR HANDLING UNIT CTO 10,000 CFM) SUBTOTAL:
i,SAs2ld City in"none"
of the granting of this permit.
/ l� /- AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
i� i2_ g�
Signature of Applicant/Contra Date EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle harardous HEATING UNIT(TO 100,000 BTU) Date RCCeI t#
material as defined by the Cupertino Municipal Cade,Chapter 9.12,and the -
Hullh and Saf&y Code Section 25532(a)7. s� HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes H No //I/yy'}!'�-- ,.{�[{T'����
Will the applicant orfu[um buildingocu�t4skequipment ardevices VENTILATION FAN(SINGLE REBID) ISS 'DATE
which emit hazardous air conn eurants as defined by the Bay Area Air �'R:aLJ
Qua lity Ma nagement District? //++�Sjj'' // BOILER-COMP Ohl'OR 100,IXU BTU) �k
4hYesavcrcadtheh. moiomaterIsisrequ7rraderChapter 6.95of BOILER-COMP(OVER 100,000 BTU) ok(N 7 »9�j
the California at if th building
currently have.tenand,that 1
understandaliforia Ilesthe Safengdoesnmcions, l505, c&tenant,that It Is my N'EW RESIDENTIAL MECFi. 'SQ.FT. �a��TN
rrsponsiboit to notify the occupant of the requirements which most be met
prior to ua im
m of a afl al ea Occupancy. 1:HYSIEIY �./�
ia- 7-9D
Ownerorauthoozed agent Date TOTAL: ISSUED
OFFICE COPY
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