19766 APPLICANT TO FILL IN INFORMATIONWITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification - ' PFIMT NO.
Buildln Addrex: 19766
ams: P one.
mer; f e CITY OF CUPERTINO-BUILDING DIVISION ,� —�j D
Contractor's Name: ����.��,,..yyLlc.N. APPLICATION / PERMIT ee
L 2405 BUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL# ,
Architect/Engineer. LIc No: -
w ir`;'. ` ,tELEC�RIG PfiB NIT1 • 1
FEE BWI$EIINGPERMITINFp
Addrex: ay A . 5Q 9I'i-i PERMITISSUANCE ILWMU
❑., ❑..•..� f\/� .•.
LICENSED CONTRACTOR'S DECLARATION L—`•I,
I hereby affirm that l am licensed under provisions of Chapter9(commena APMANCESRESIDE - JOB DESCREIMON
Ingwith Sedion7000)of Dlvlsion3ofthe Businessand Profess(onsCode,and my .,
Iice x le In fuyr(od PANT
IS
1q
Date Contractor _
`� to ARCHITECT CIA ATsU c N.: OVFR1000AM
oto Z I understand my plans shall be used u public records: OVER 1000 AMPS - SQ.FC.FLOOR AREA $/SQ.FT.
qO �
jw4(� Licensed Professional - SIGNS ELECTRICAL
<�'c - OWNER-BUILDER DECLARATION -
lh..by.ffi.tt4tl..e.emptf.th.Contractors SPECIAL CUIT/Li....,tUWfo,the _ _
a lowing reason.(Section 7611.5,Business and Professions Code:Any city or p M- A OR INST.
'
' .c which requireea permltto construct,alter,Improve,demolt, orrepalr
TEM
aeyst re pdorto its lssance,alsorequlreathe appll6nt forsuch Ixtto
file a sl statement that he E licensed pursuant to the provelonsof the ]OWER DEV
OOH Contractor's cense Law(Chapter 9(mmmendnjwlth Section7000)ol Divi- SWIMMINGECTRICAX
E„ eion3ofthe Bu essand ProfessimuCode)or fiatheisexempitherefromand - 'VALUATION
the basis for the of exemption. Any olalion of Section 76115 by any
.yob appliantforapereni bjeRstheapplic ties civil penalty ofnot morelhan OUTLEISSWI
nn Q
five hundred1,asonerals( STORIES TYPE CONSTRUCTION
.`p+i�• tNEW RE9IDENTTAL EL TR
❑I,as owner of the pro rty,or employees with wages r there sok '
compensation,wfl!,.. wor the atrodurela not intended or offered for
q sale(Sec.7044,Busimas and P to.Code:The Cmdractofs License Law
doesnotapplytoanowner prope who builds arimproveathereon,and
' whodoessuchworkhlmx orthmogh own employees,provided that such OCC.GROUP RES.UNITS
improvereentsarenotin ndedoroffered sale.If,however,thebulldingor TOTAL:
Improvereenthsold inoneyearofcwnpl on,theowner-builderwlll have "
t Menofprovl that he did not build or roveforpurpoeeofale) (17'y, „ PI;UMBIIVp'PBR11'fl'T ,Its ,it FEEi:: FLODD ZDNE APN
L as owner f the property,am to tracing with licensed PERMITISSUANCE
entracton to trod the project(Sec,7044,Buslne and Profession;Code: a
The Cont. is Limnx Law does not apply to an o at of property,who ALTER-DRAIN&VENT-WATER(PA) "
Wilds or proves thereon,and who contracts for so injects with a ..
cga4far Licensed puesuanttothe Contractor's Limnx La 8yg>;.aFEE SUMMA$Y''
LL�JPLOW PROTECT.DEVICE
m exempt under Sec. B&P C for BACK reason
Owner DRAINS-FLOOR,BOOP,AREA,GOND: OU
SANITARY Y N
.;• ECL RECEBPI p
WORKMAN COMPENSATIONveaoune,ofc RATION FD(=S.PER TRAP SCHOOLTAX Y N
I hereby af(lim that I have a certIDateof consent to selfdnsure,or a RF('EIPI,#
mdiflmteofWorke 'ComPensati.. uanceoramrtifW copythereof(Sec. CAS EA.SYSTEM-I INCA OUTLETS PARK FEE Y N
ivi38W, #b C.) �p ) �'y/J-�6+' AiD RECEIPT If
Iolcy# ����'S/`qG J/F//G- �— GAS EA,SYSTEM-OVER4(EA) . BUILDING DIVISION FEES
Com nv /
FCertified copy i (Fled withthe cityInspecdon dlvlelon.eklfiedcopybherebyf )shed. CREASE/INDUSTILL WASTE INTERCEPTOR PLANCHECK FEE
Cs
CERTIFICATE OF EXENIPIION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SpM.I.ARY-SNRM EA 200F1, - Date Recei t# '
This sed mah"completed l(the permi[le for one hundred dollam
($100)or less.)' WATER HEATER W/VENT/ELFCTR ENERGY FEE Y N
I certifythat Nthe performanceo NchethE.permit is Issued, —
I shall net employ any person In any manner so as to bject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID
0 Z Applicant NEW RESIDENTIAL PLMB. SQ.Ff. Date Recei t#
Z p NOTICETO APPLICANT:tothe ager, kinrs'Co per ;tion pro is Exemption,you
should becoat me forth note Worker%Cuch provisions
orchis permitions of s Lab be TOTAL:
Uj W de,youvoked.forthwith comply with such provlalom orchis permit shall be ' BUILDING� dee d revoked.
W - CONSTRUCTION LENDING AGENCY SEISMIC FEE
d Iha.bya thatthereise comtrurtion lending agency for the perform ELECTRIC FEE
D Z anceoftheworkfo Ich thispermit E Issued(Sec.3097,Civ.C) - TOTAL .,
C1 O ender';Name p PLUMBINGFEE
LL I- Lender's Address - QTY,''•,'c`rMECHANICAL P.ERNtIT� '.': E'`•`' MECHANICAL FEE -23,op
OW Icedlfythat]havereadthlsappliatlon lhatthe above ln(ormatim
Q. Ie corrert.]agreeto comply wllM1 all city rountyo n sand state laws PERMIT ISSUANCE' ja, FEES PAID:
�. relatingtobulidingmnstmctlon,and herebyauthorize exprexntativeso(this - - ,
Zcity to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. Date R6Cel I#
_ (We)agree to save,Indemnify an d keep harmless;the City of Cupertino Date
HANDLING UNIT CIO 10,000 CFM)
against liabilities,judgments,emlsand expenses which may In anywayacrnae SUBTOTAL:
ag.ust.!0CItylq cons ofthe socio of this permit _
.y racy- ,���A Y! tel/ AIR HANDLING u1.gT(ovER1B,BBocr•M) CONSTRUCTION TAX
Ignature of Applicant/Contractor a Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfutom building oecupantstore orhandle hazardous HEATING UNIT CIO 100,000 BTU)
-a rm[edal ae defined by the Cupertino Municipal Code,Chapter 9.1$and the _ Date Receipt
health and Safety Code on 25532(.)7 HEATING UNIT(OVER 100,000 BTU) �QO TOTAL' 40
r_1Yes No '
Will the applicant or future building oompanfuse equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haaurdous air contaminants as defined by the Bay Area Air
Quality Management Distd BOILER-COMP(3HP OR 100,000 BTU) /'La6M
f n Ym o - -
l� Ph read the hazar ausmeterials rcqu Imments under Chapter 6.95 o6 BOILER-COMP(OVEd 100,000 BTU) -.j f3J�,
the California Health&Safety Code,Sections 25505,25533 and 25534.1 - - JULU �, q J
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FI.
r pomibI ity to notify the occupant of the requirements which at be met
prort uance Cerfift a - 'City of Cupertino
'fhv
or aulhorl gent' a rd t
TOTAL: ISSUED 8Y;
OFFICE COPY