19740 APPLICANT TO.FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
auildin m
P 'ect identification _ PERMIT NO.
Hding Address:(_27 80 19740
cane s ante: - Phone: __XMTri7XTMN_9=AL DATE
CITY OF CUPERTINO-BUILDING DIVISION
Coetractors Name:, Lm.No: APPLICATION I PERMIT- 2. `
BUILDINGELECTRICALPLUMBINGMCCHAMCAL CATEGORY CONTROL#
Architect/Engineer, - Lk.No ..
::ELECTRIC PERII'lIT i;.FEE i' "BUILRINC FfiRMIT•1NF0
Address: - - PERMITISSUANCE ' - L00 ❑
LICENSED CONTRACTOR'S DECLARATION
•I hereby affirm that l am licensed under previsions of Chapter 9(commene- APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwlth Sect1on7000)of Divlsion3 ofthe Businessand ProfessionaCode,and my -
license le In full force and effect. PANF1 S _
License Class LIc.N
Date Contractor UP TO 200 ANTS
ARCHITECT`S DECLARATION 201-IOOOAMPS
NO Z I understand my place shall be used c public records. OVER I00D AMPS SQ,FT.FLOOR ARTA $/SQ.FC.
O
�j Licensed Professional ' SIGNS ELECTRICAL
< OWNER-BUILDER DECLARATION SPECIAL CII4CUfT/MISC Q
E„ Iherebyafflrmthatlam exempt from the Contractor's License law for the
7.O foBowing reason,(SeRion 70211.5,Business and Pmfe clone Code:Any city or
Feau 7F1v1P. OR POL ST. '
Mf stmm pdmtesape anceakom uirestheapmmatfor llah,ormitt"
< a anyetmdurc prlorm iro Wuan<Gaborcqulreetha applicant meuchperfNt a POWER DAt:4
K� U file a signed statement that M is licensed pursuant to the provisions of the '
Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi.
�0 aloe 3 ofthe Business and ProfeaageonCode)or that he le exemptthercfromand SWR,] G LEL TRIC VALUATION
the basis for the alleged exemption. Any violation of Seciion 7031.5 by any OUTL TC XTURES
•�k?c applicant for a permit subjects,the applicant to a civil penalty of not more ttSn
liveundreddolUre($5DB. NE ID EEC SQ.FC. STORIES IYPECONSTRLICTION
I,as owner of the property,or my employees with wages as their sole
7¢ mm esatlon,willdothe work ancithe structure is not intended or offered(or
O sale(Sec.7044,Business and Professiom Cade:The Contractor's Lt...Law
$ does net apply to an owner of property who Wilds or improves thereon,andOCC.CROUP RES.UNITS
who daeasuch work himselforthrough his own employees,provided that such yj
improvements are not Intended or offered for sale.If,howovep the building or ,TOTAL:
i provementissoldwthinoneyearofcompletron,theawner WBderwillt ve, „ .
t burdenof proving that he did not build or Improve for purpose ofsale). QTY;?,,•, 'PLUMBING'.PERMIT '.' FEE';•. FLOOD ZONE APN
I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE.
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contender's License Law does net apply to an owner of property who ALTER-DRAIN&VENT-WATQt(EA)
Wilds or Improves thereon, and who contracts for such ptoJects with a t
=,t FEE 5UMI�t(gy"
cq➢Ilactor(e)_Ikenae under Snt to the Contractou Lk&PLaw.. BACK FLOW PROTECT.DEVICE
�j I :;;;;Z t-under Sec B&P C for this reason � '
�\ Owner ! Date DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y— N_
RECEIPT p
VORKMAN COM SATION DECLAR ION FIX.NRES PER TRAP SCHOOL TAX Y_ N_
❑I hereby affirm that I have a certificate of consent to self-Insure,or a RECEIPT p
certificate of Workeri Compmeatlonlnammom rot earffiled elpythereof(See.
350,Lab C.) S GAEA.SYBTEM-1INCA 0UTLECS PARK FEE Y N_
Policy 0 RECEIPT a
GAS F.A.SYSTEM-OVER 4(EA)
Com any. - ' BUILDING DIVISION FEES
�
Certlfied copy la hereby fumlahed. CRPASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE -
CertEed copy is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORK ERS' GREASETRAP PAID---
COMPENSATION
AID COMPENSATION INSURANCE SEWER-SANITARY-STORM EA,2tion Date Remi t#
Cfhissection need not W completed lithe permit tifor one hundred dollars
N_
I
'($1moelesa.) N - 'certi(ythat the performance of thewark forwhkh<hle permit le Issued, WATERHEATERW/VENT/ELECTR ENERGYFEE Y._ -
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
worken'compensation Lawsof California.Date PAID
Q Z Applicant NEW RESIDENTIAL PLMB. SQFf. Dale Recei t#
Z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should here=subject tothe Workers'Compeneation provisions of the Labor - TOTAL:
CCN Code,you most fort hwith comply with such provisions or this permit shall be
m _ BU N FEE
LU > deemed revoked.
CONSTRUCTION LENDING AGENCY t SEISMIC FEE
S I hereby affirenthet there is a construction lending agency for the perform-
'. - ELECTRICFEE
Z Larderthe work!or whlchthls permit laLswed(Sec.3097,C1v.C.) TOTAL: Q
O Iandere Name 77—. PLUMRINGFEE
'
H Landers Address '1vIECHANICAL;PEEMIT ,�EEG1'i
LL MECHANICAL FEE
OW Iceditythatl have read this application and state thattheaboveinformatlon
CL Lscorrect.I agreeto comply with all city and county ordinances and elate laws PERMIT ISSUANCE FEES PAID:
>. relating to building construction,and-hereby authorize representatives of this
I.- N city to enter upon the above-mentloned property for inspection purposes. ALTER OR ADD TO MECH. -
? (We)agree to save;Indemnlfy an d keep harmless the City of Cupertino Date Recei t#
V agairet Babilitles,lydgnnenta,coatsand expened:e which may inanywayaeman AIRHANDLINGUNIT(TO 10,000CFM) SUBTOTAL'
agaiwt City In conaryue a egr'� fife of this permit AIR HA NDLING UNIT(OVER 10,W0 CFM) CONSTRUCTION TAX
z 2f 9d CONSTRUCTION TAX PAID:
Sigwture of AppBcantl ractor Date- IXHAUS'C HOOD(W/01X:'0,'
HA7ARDOUS MATE RIALS ISCLOSURE
Will the applicant or future building oavp ret store or handle hazardous HEATING UNIT(TO 100,000BTU) Date Recei t#
material as defined by the Cupertino Municipal Cade,Chapter 9.12,and the
He❑alt,and Safety Code,Sectiion 2S532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL•
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISPJAND DATE
which emit hagem nt Dis riot? pants,as defined by the Bay Area Air _
u�hichcMawaardou manst cont BOILER-COMP(3FNOR 100,000 BTU)
No
I have read the bazars s materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) s �•� y '¢ �� 4
the California Health&Safety Code,Sections 25505,25533 and 25534.I
understand that if the building does not currently have a tenant,that It is my NBWRFSIDENTIALMECH. ' SQ.FT.
responsibility to notify the occupant of the requirements which must be met CI4/frip B} rlln?1,t11I,n
prior to issuance of a Certificate of Occupancy. -
Owneror authorized agent - Date - ISSUED
' - TOTAL: '
OFFICE COPY