19474 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project identification - PERMIT NO.
Building Address; "
2--oTTSA cur,�Rr,�o 19474
neION SU HWII77�L�
A4R a-_. Phone:MRS,- 10-SETH Owl- - -. .
CITY OF CUPERTIN0.BUILDING DIVISION
Contractors Name: I Lic.No: . APPLICATION /PERMIT
f( a 0d Co- r 'BUILDINGELECTRICAL-PLUMBING-MECHANICAL CATEGORY CONTROL
Architect/Engineer. NY R Llc,Ne: '
'QTY ELECTRIC PERMIT' FEE BUILDING PERMIT INFO
Addrees: 5'Iri �AJ7ub)Z CAM PERMITISSUANCE PLUMB(� t❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter9(mmmena APPLIANCES-RESIDENTIAL - JOBDESCRI770N
ingwith Se on 7000)of Divlslon3 ofthe Business and ProfesalansCode,and my .
license is in full fo and ailed. ♦ PANEiS ' /,t4,.rN
License Cla Lic.R .�Y�a 8D 1 - •/ l��� Q�
Date' Contraaor�D((,- GTe/CUP TO 2DOANIPS
ARCHITECTS DECLARATION 7014000 AMPS
p�p�vvQCOCIundemtandmyplamshaRbeuwdaspubhcremrds OVER1000AMPS - SQ.FT.FLOOR AREA $/SQ.FT.
}i od U Licensed Professional SIGNSELFOTRICAL
< ul
6 OWNER-BUILDER DECLARATION
a SPECIALCIRCU[T/MISC
Ze., owing cafnrmthat Iamexempt 31.5,B(romthe Contractor's License Law fort he
pp following reason.(Section 78115,Business and alter,imps w, Code:Any rep it
'.0Z,t.� TEMP.METER OR POLE INST. ." � -
county ctur,requires pemNce,atsutmuireatheapmventfors ch,orrepalr
any atmdure t.menepriorto lbhat he to licensed
pursuant
t the provisions
such of it a POWER DEVICES
file a signed statement that he h licensed pursuant it the pro 7000) of the
3µ Contractors License Law(Cha pter9(commencing with Section 7000)o(Dlvl- VALUATION
In SWIMMING POOL ELECTRIC
elon3o(Ihe Busineeaand ProfembruCade)orlhat hely excmptthere(romand
�5epu o•] the bash for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESFIXI'URFS 6e� /I,)
9 Q• aJ O
appReent fora permit subjects the applicant to a civil penalty of not more than a t1
�j five hundred dollars($500). 5Q.FT. STORIES TYPE CONSTRUCTION
C"C NEW RESIDENTIAL ELECTR
�n ❑Las owner of the properly,or my employees with wages there sok
compema 0K wllldothework nd Pre essi eatrudurehnot
ontrandedctor or License
d for
I..
saIn(Sec.apply
Bushes and f property Code:The Contractors the me Law _
docs not apply to an owner of property who builds or improves Ihereory and OCC.CROUP RES.UNITS
whodoe.entsasmchor khMsendedcroffe ed owns.If,hoea,pr thebu lding r
improvementsarenot Intendneyearffc=prsal thho ee buUderwdI have TOTAL:
improvement hervingsold that
he did otbuil plr Improve
purpose
of sale.). off- 7 5•
IILe-purdenofpmving that he did not build or improve for purpose o(mleJ. QTY. ,PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT SSUANCI
contrsctors to mec.natmd the project(S 7014,Business and Professions Code:
The Contractors License Law does net apply to art owner of property who ALTER-DRAIN AVENT-WATER(EA)
belles or improves Ibende, and who contracts for such projects with a Y FEE SUMMARY
��RRlCactor(s)licensed pursuant to the Contractor's License Law.
L,J I am exempt under Sec. - B k P C for this reason BACK FLOW PROTECT.DEVICE
Owner Date
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y' N
RECEI7 M
WORKMAN COMPENSATION DECLARATION FIXTURE&PER TRAP SCHOOLTAX Y N
❑I herebya(firm that I have a certincare of consent to self-Insure,ora - RpC=M
certificate ofWorkes''Comper atlonlexurance ora certified mpythersof(Sec. GAS F.A.SYSTE24-1 INCA OUTLETS PARKFEE Y N
3800,Lab C.) - RECEIPT
Policy M GAS F.A.SYSTEM-OVER 4(FAT
Comany - BUILDING DIVISION�Cerlified copy h herebyth the city CREASE/INDUSCRL STF 1NTERC PLANCHECKFEE 33
❑CedKletl ropy h Mihai with the city impaction dlWelon. / /�.�' A
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP - PAID 1-+fO � t
COMPENSATION INSURANCE SEWER-SANIT Y- EA. FT Date Recei t><
(Thissedlon need notbe completed l(Ihe permit is torous re
hundd dollars
(BIC(Borless.) WATERHEA / ec.I:R ' ENERGY FEE Y N
I certifythat in the performance of the work for which this permit la Issued, -
I shall not employ any person In any manner so as to become subject to the -
WorkeW Compensation laws of Callfomla.Date WA SY NO PAID
Z 0 Applicant Date Remi tic
NOTICE TO APPLICANT.If,after making this Certificate ofFxemptlon,you PLMB. SQ.
should became subject to the Workers'Comp....it..provlslom o(the Labor v, TOTAL:
N Code,you most forthwith comply with such pnwislom arthis percetshall be BUILDING
FEE
LU j deemed revoked.
CONSTRUCTION is a ON LENDING AGENCY SEISMIC FEE -O
D Z eofth work.ffl"!thatthemt hammtmctlond lending agency Civ. .) pedomF TOTAL: - ELECTRIOFEE .�
� Tender the work(or which this permit hiswed(Sec.3097,Civ.C.)
(.) 2 lender's Nan.' - PLUMBING FEE
I4, F LendersAddresa QTY. ECHANICAL PERMIT FEE on MECHANICAL FEE
OW Icect. thsal Iameto complyad happllcitynand dcuntyordinances ndgatelaws
, 'L hco,mtobuilding comtmotioh andtyandcouhorladmpreseand gate laws PERMIT ISSUANCE ��� FEES PAID:
�. U) relatingoenteru pont cotutructiontioned rebyrty orizerepreaenpurpon of this
(— cltytaenteree to theabovemnify an d property harmless
Cit purpose. ALTER OR ADDTO MECH. QaQ�
Z Date Recei tN
(We)agree to cave,Indemnify and keep harmless the City of yCupertino -
V against liabilities,.senh,metsand expenses which may in anyway same AIR HANDLING UNIT OO l0,lXq CFM) SUBTOTAL:
against sold City in consequence of the granting of this pennB' CONSTRUCTION TAX
AIR HANDLING UNC!(OVER]O,lXIOC[M)'
Signature of Applicant/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE -
Willtheapplicantmfuture building occupant store or hand le hazardous HEATING UNIT(TO 100,000 BTU) Date Recei tM
material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the
Healthand Safety Coder.-S�ection75537(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: (r
❑Yes u No
Will the apphcantorfuture building occupant use equipment or devices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE -
which emit hazardous are contaminants as defined by the Bay Area Air"
lity Management El No BOILER{AMP OHP OR]00,0(10 BTU)
Yes ❑No �1L.fix q
s have read the baaaMoua materlah iequircmenls under Chapter 6.95 of BOILER-COMP(OVQt1W,000BTU)
the CalBemis Health A Safety Code,Sections 25505,75533 and 75534.1
understand that lithe building does not currently have a tenant,that it is my NEWRESIDENTIALMECH. SQ.I7.
respomibllity to ndify,the occupant of the requirements which moat be and -
prior to issuance of a Certificate of Occupancy.
Owner or authorized agent Date
TOTALISSUEDBY: V CJEE n4-W"-`L` 4
: c
OFFICE COPY _
— -aid