19627 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proert Identification PERMIT NO.
P
Address: 9 6 2 19627 7
�nvnes ams: p _ I J (�
'4+Q�x �a�� l�� • / CITY OF CUPERTINO-BUILDING DIVISION r
C°^ Nam: LIc.No. APPLICATION / PERMIT Z"7
t BNLDINGELECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL Y
Arc Iles/Englmer. Lk. o:
QTY ELECTRICPERMIT FEE �a��BUILDING PERMIT INFO
Add. PERMITISSUANCE ��/� 1:1 1:1 1:1LICENSEDCONTR DECLARATION L�
Thereby affretn Hui lam licensed
sed under provisions o(Chapler9(mmmmc- APPLIANCES-RESIDENTIAL JOB DESCRD'TION
IngwllhSMio^7000)of Divi.lon3ofthe Bustw andProfmlonsCode,andmy
License is in full( and erfM. PANELS C�\rn �y f�
License la L-m
Dat< Cantractor�, He ra.v
ARCHITEGTSDECLA ION 201-1000 AMPS
p�uuce0 O I understand my plans shall be used u public records. OYER 1000 AMPS SQ.FT.FLOOR AREA $/9Q Fr.
k
Licensed Professional SIGNS ELECTRICAL
«<<<(�❑u� OWNER-BUILDER DECLARATION
I"n 4L SPECLILCIRCUIT/MISC
Zf, Iherebyafflrm that am exempt from the Contractor's License law for the
po following reason.(Beaton 7011 S,Businm and Profmions Code:Mycity or
Kz TEMP.METER ORPOLE INST.
� countywhkhrequlre.a pertNt/oconstmct,alter,improve,dertnWh,orrepalr
anystmc mpriortoit.esmance,alsomquimtheappBmniforsuchpermitto POWER DEVICES
le a signed statement that he is licensed pursuant to the provisions of the
Contractors License Law(Clupter9(mmm°ndng with Section 7000)of Divi- SWIMMI NG POOL ELECTRIC
slon3 of the Businessand ProfmionsCode)or that he Is exempttherefromand VALUATION
the bases for the alleged e.empion. Any violation of Section 70315 by any �(� h
applicantfor a permit subjeathe applicant to a civil penalty of not more than OUTLETSSWITCHESFl ES
tJ oV
O$ (Ivehundreddollar($500).
C`c NEW RESIDENTIAL ELFC SQFC. STORIES TYPE CONSTRUCTION
�n ❑Lasownerofthe property,orhe employeeswithwages r theresole
compce.70 ,B. oess an Peanghms Codurch notintended oroffered for
O sale(See 7344,euelnees and Profmlom Code:The Contractors License Law
3$ d..en .pplytoanownerufpropertywho Wlldsorimprovesthereon,and OCC.GROUP RES.[NIT5
who daessuch work himself orthrough his own employees,provided that such
Improvements are notletended oroffered[mule.IIluescoegthebulldingor T AL:
Improvement issold within one yearof compltlun,the owner-W Rderwill have
IlLkurden of proving that he did nm Wild or Improve for purpose of sale.). QTY. P&MBINC MI FEEFLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed . W
contractors to mnriruct the Project(Sm.7014,Business and Profeulom Code: PERMIT CE
The Contractors License Law does not apply to an owner of property who
W Ills or Improves thereon,and who conangs for such pW*U with a ALTER-D - ATER )
CDbator(s)licensed pursuant to the Contractor's License Law. FEE SUMMARY
LI I am exempt under Sec. B k P C for this mason BACKFLOW DEVIC
_ OUTSIDE FEES
DRAINS FLOORR F,ARFA,COND. SANITARY Y_ N
Owner Date REQII'I'Y
WORKMAN COMPENSATION DECLARATION FUTURE&PER SCHOOL LAK Y N
❑I hereby affirm that I have o !esu ate of consent to copy
ts a RECEIPT N
certltinte of WorkersCompematlonlmunnce ma certified copy thereo((Sec. GAS EA.SYSTEM-1 NCA OUTLETS PARK FEE Y N
3800,Lab Q RECEIl71'M
Policy Y
CGAS EA.SYSTEM-OOVER (EA)
C. any BUILDING DIVISION FEES
ECertified copy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy is filed with the city inspection division. _
CERTIFICATE OF EKEMFTION FROM WOR KERS' GRFa SETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA.700F1'. Date Relxi [#
Ohis section need cat be eomplted If the permit es faros hundred dollars
($10(fimlm.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I certifythat N the performance of thework forwhich this permit is issued,
I shall not employ any person in any panne o as to become subject to the
WorkrEn'tT p .tionNlTa:s oftf eCr amll(aokminlag.thes CIraortl,fkate of Exemption,YouWATl3SYSTEM/TREATING
PAID
O ZApplicaNEW RESIDIiAL PLMB. SQFT.
Date Ri t#
Z O NOTIC
should
TOTAL:
N Cade,You mus hwfth comply witheuch proveslom orches pemdt shall be QO
`� deemed revoked.
U — BUILDING FLE
CONSTRUCTION LENDING AGENCY SEISMIC FEE a'r
CL IhembyafRrm thatthereese comtmetion lending agency for the perform ELECTRIC FEE
M Z ance of the wurkfor which thlaperMt is iasued(Sec.3097,Civ.C) TOTAL:
(),O Lender.Name PLUMBING FEE
LL F Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1certifythat i have read thisepp0otion and statethattheaboveinformation
1 Is correct.l agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
�. N relating to building comtmctiory and hereby authorise representatives of this
II to enterupon the above-mentioned farW Ion s ALTERORADDTDMECH.
~ ? city
agree save,Indemnify an d kkrep harmless the inspection
of Cupertino Date Receipt# .
V
against liabilities,Ndgments,cestaandexpenses which mayinanyway aorue AIR HANDLING UNIT(TO 10,OWCFM) SUBTOTAL: L[_
a id CityIn ronsequerec of the gr ting of Ihl.permit
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX
0!299
Signa pp n Detractor ' Date EYHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA RDOUSMATERIALS SCLOSURE
W1n the applicant orfcture building occupant store orhandlehazackrus HEATING UNIT(TO I OO,OW BTI)) Date Recei t#
material as de(Imd by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 75531(.)7 HEATING UNIT(OVER 10,000 SM TOTAL:
❑ Ym No
Will the applicant or ture building occupanlaseequipment or devices VENTILATION FAN(SINGLE RESID) ISSLlAI9(�,DATE
which emit haurdous air contaminants as defined by the Bay Arca Air JW
Quality Management District? BOILER-COMP OHP OR 1001000 BTU)
iYn M❑No FEB �
��
svereacilhehazard..materialsmquim=ntsunderChapter6.95of BOILER-COMP(OVER 100,000 BTT) LL7 u 'I ly✓
the Callfomia Health k Safety Cade,SMiom 2,55a5,25533 and 25534.I
` -
contend rd that if the building don not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQFF.
mpoialb0lty to notify the occupant of the requirements which must be met /r'a,( 1s11nOyjnA
prior to Lssuance of a Certificate of Occupancy.
Owner or authorized agent Date TOTAL: : — H ISSUEDBYlkUG
OFFICE COPY