19517APPLICANT TO FILL IN INFORMATION WITHIN RED, LIN ES —USE BALLPOINT PEN ONLY
Building Project Ideroificatien�C, 4 f"n (^ ' • , -
Bulldmg Address: - / _ ,.
PEMTNO.
7
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19517
W�ere sure. Phone:
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CITY OF CUPERTINO-BUILDING DIVISION
tA,.-y-� APPLICATION /'PERMIT
/P6gf ,NG-FlECTMCALPLUMBINGMECHAMCAL
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Contractors Name: /' LIc. No.
' 4 LQ•, a o wNe_ -
CATEGORY
«
Architect/ g,�/ � lc. Na: _
' r " I x'"'
ir iECRIER,�ye�d, C
IT •-,i
l ; 4 .AL+: •FEOEb
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D�ING't.EECROMNTIRTOjILN
Addre („/e
, PE MITISSUANCE -
- LICENSED CONTRACTOR'S DECLARATION
Iherebyafirn that lam icnsed undeiproxislons ofChaphr9(mmmen
APPLIANCESRESIDENTLAL
)OBDESCRIIDON,
Ingwilh5 dion9030)of Dlvision3ofthe BuMnessand PmfessionsCode,andmy
license le o full f re and effect..-
LlmnseCla= .- affect.
C
Date ontractor Op•r4-c.{4,
- ARCHITECT'S DECLARATION .'
Iunderstand my plavahall be used as public records.
UP TO 200 A
'-
701-1000 AMPS
OVERI"AMPS
SQ. FT. FLOOR AREA'
9/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional - - -
t / �•D�
^
SPECIAL CIl2CUIT/MISC
OWNER -BUILDER DECLARATION
I hereby affirenthat l am exempt from the Contractor's License law faiths
b '
- -
,
TEMP, METEROR POLE INST.
following reason. (Section 7631.5, Business and Professions Cade: Any ctty' or
county which requires a permit to construct, alter, Improve, dermlish,orrepair
-
-
anystmd mprl.rtolhhmaance,alsorequUestheapplianfforsuchpermitto
,file a signed statement that he is licensed pursuant to the. provisions of the
POWER DEVICES
-
SWIMMING CTRIC
Contractor's License Law (CMpter9(commnncmg with Section 9000) of Divi-
sion 3 of the Business and Profemlons Code) or that he is exempt therefrom and
VALUATION
.the basis for the alleged exemption. Any violation of Section 96115 by any
penalty elect ore than
applicant fora permit subjects the applicant to a dum
five Nuns owner thepro
I, as owner of the property, or my employees with wages as their sole
TGHFSFI 'F9 .
OUTLPll e
` r�OQcn,
RESIDENTIAL ELEC SQ.FT.
STORIES
TYPE CONSTRUCTION
compensation,wBldolhe work andthestrodure is not Intended or offered for
sale (Sec. 9044, Business and Professions Code: The Contractors License Law
--
docs not apply to an owner of property who builds ar Improves thereoM andOCC.
doessuchwork himselfortheaugh hisownempleyees,provided ihatsuch
improvements arenot Intended oroltered forsak. IL hmvevrg thebulldingo
#J D-
TOTAL: I -�
GROUP.
RFS UNITS
improvementisa.ld within oneyearofcompletion,the ownerbullderwill ha
t)Lkuben of proving that he did not build orimprove (or purpose of eak
Lj L as owner of the property, am excluelvely mntracnng with Ilcen d
contractors to construct the project (Sec. 9654, Business and Professions de:-
Q'{yt';EERMITt`4r t3`''+:"PEE ,i
FLOOD ZONE,
- APN
.
'
Fir
The Contractordo
Contractors License Law es rustapply to an owner of property ah.
Wilds or Improves' thereon, and who contracts for such pWjeda th a
cgB((actcr(s) licensed pursuant to the Contractor's License Law. -t-
u I am exempt under Sec, B & P -C for this .son
AL -D & WATER (EA)
w .DEVIM
OUTSIDE FEES
-
DRAINS F
SANITARY Y N
RECER T pSATION
Owner - Date
WORKMANCOMPENDECLARATION
❑I hereby affirm that I havea certificate of consent to self -Insure or a
mklticateofWorkers'Comperesatlonl.ranceoramrtlfWd opythereo (See.*
3830, lab CJ -
Pollq « L'. Q Vest 7 °
SCHOOL TAX Y N -
T
REC- N
1
CAE as
-
PARK FEE Y
HE=«
-.I?M-O
4 (EA) V
Com any K: ..BUILDING
DIVISION FEES
�a edcopyis releyfarnh ed: "
hifed copy is filed with the city Inspection division.
STRL WASTEI TOR
PLANCHCCK FEE
`1
� xl�
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID '
SEWER- -STORM EA. 2001717.'
" COMPENSATION INSURANCE,
(Th .meti.n need not he completed if the permit isforom hundred dollars
Date ReC'EI 1#
WATER [iEATER W/VENT/Q.EC7R
ENERGYFEE' Y N
—
($100)or less')
I artifythat in theperfor ance of the work for which this permit is issued,
-
WATER SYSTEM/7REATING.,'
I shall not employ any person in any manner so as to be= subje o e
W.rkcrsComensa nL,-� of Calif.mW.Date —
PAID. //Z/ J `Dia
. NEW RESIDENTIAL PLMB. SQ.FT.
Applicant
NOTICE TO :ILsuer ng his etlll®Exemption, mption, you
D�1Rte' Recei t#i
TOTAL:
'
should become subject to the Workers' Compensation provisions of the Labor
Code, you most forthwith comply With such provbdom orthispermit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
BUIL
• 0 0
'
SEISMIC FEE
.
e --w
a y
Iherebyaf(Irmthattherehaco.trudioIendingageneyfortheperlorm-
ance of the work(orwhlch this permit (Sec. W, Civ.C)
Lender'sName
Lender's Address' - - -
Imrtifythatl have readthisappilationandetatethattheabove Information
Is colied. I agree to comply with all cityand county mellmems and state laws
relating to building construction, and hereby awh.dae representatives of this
city to enter upon the above-mentioned property for bupectt.n purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
against Rabiiltka,judgmenh, costs and expenses which may lnany wayamrue.
-TOTAL: -
ELECTRIC
y- .. -4,.
QTY.'"` ,•'MECHANICAL EfiR T t . ;r;. FEES.,
PLUMBING FEE
MECHANICAL FEE '
PERMTTISSUANCE .
FEES P D: �6
_
,
.' ALTERORADDTOMECH.
Date -' Reeel til
. AIR FNNDLING UNIT (LO 10,000 CFM)
-
SUBTOTAL•
against said City in mnaequea✓of the Ba ming of this permit..
/.... L11,"4 !O .� .�- ,� O`�_2.,�1.
N
✓of
AIRKANDLINGUNrr(OVER I0,ro0c.)
CONSTRUCTION TAX •.
Signature Applicant/Cyntrraad'orr "' Date-'
EXHAUS'THOOD(W/DUCT)
-
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
" HEATING UNIT (TO 100,000 BTM .�
Willtheapplicantorluture building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Healthand Safely Coder. -S�ection 25532(a)2
❑ Yes I u No ..
"
Date'1 RBC2I IN
-
HFATING UNIT (OVER 100,030 BTU)
_ TOTAL:.
VENTILATION PAN (SINGLE RESID)'
ISSUANCE DATE
Will the applicant orfuture building occopant use equipment or devices
which emit hamnims aucrowminantaas dellMd bythe Bay Aica Air
Quality Management District? -
4Yrs QmNo
h ave read the ha a3Ousmateria quUem nhunderChapter6.95of
'1T"AR�f
BORER-COMP(3HPORI00,000BTU)'
BO ER-COMP(OVFRIW,OWBTU)
the California Health&SafetyCode, Sections 25505,25533 and 28534. I
understand that if the building does not currently have a tenant, that it is my
resp...ibility to notify the ..pantof the requirements which nw,I be net
prior to nce of Certillcate of Occupancy.
q�{
JFiIY {±rs "L
A 23 IJ.%d
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ISSUED BY: �P✓N L��'l'En
NEW RESIDENTIAL MECH. SQ.Ff.
-
Owner or authorized agent' Date
.,
TOTAL:
V
OFFICE COPY