19790 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY V
Building PmIect Identification ¢ PERMITNO.. 7
IZa Aaarea.: - 19790 J 1 Q J O
mrtlan,e hone: A
CITY OF CUPERTINO-BUILDING DIVISION -;s—Lj_r{O
ono °e N• ' Lie.No: APPLICATION / PERMIT
Y4,62 BUR,DING-ELECnUCA4MUMBINGMECHANICAL CATEGORY CONTROL#
rchltect/Engineer: Lk.No: '
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addma PERMITISSUANCE a ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirmthat l amlkensed under prwlslonsof Chapter9(commenc APPEANCESRESIDE L JOB DESCRIPTION
IngwlthSe on7B0B)ofDivlsion3ottheBustnessandPmfesMmsC°de,and my
license Is in(ul force and d(ect. 6 PANEIS
License Cfag Llc#
Dale O Contractor_ ,
ARCHITECrj DECLARATION 201-1ODO AMPS
q�q�uu Z I understand my plana shall be used as public records. OVERI000AMPS $/SQFr
t oLicensed Professional SIGNSELECTRICAL ta-
J T) E
OWNEReBUILDER DECLARATION SPECIALCIRCIRT/M15C //S 0
p, y lherebyaf(Irm tOWNEReIIUILD R DE LARATIO License Law for the V004 1/~` v
Z O..'� following reason,(Section 7031A Budneg and ProI.kns Code:Acy ctty or
CZr9 ppQ ir TEMP.METER ORPOLE INST.
r4 anystmcounty hlch mpdwltoi permitancon rcrquia theaptwe,der.uch,or to
q raj anystrocturcpaler tethataI.also mqulressuant to
loasucmofhpethe POWER DEVICES
floe a signed statement eL that lu I.r l icurd pursuant og it the pro7000) of the
6Q Mon 3 oftheusues Law(Chaag..contrannNat he 1. xempttherefof Divi.mand
F•�Og slon3otthe Businessand Profeglons Code)orthat hebexemptlherefromaM SWIa1MING IDOL LT.ECfFUC VALUATION
gf�yi G Ne bash for the alleged exemption. Any vlulatl°n of Section 7e3S by any OUILE7SSN7TCHESFIXTURES
no mapplicant permit subjects the applicant to a civil penalty of nomthan
Fyefive hundred dollars%5M. NEW RESIDENTIAL ELECTR
WW n I,as owner of the property,or my employees with wages as their sole c"Q'FT.
61003FS TYPE CONSTRUCTION
compensation,willdothe work,and thestructum isnot intended or offend for
Osite(Sec.70K Business and Profe simu Code:The Contractors License jaw
$ does not apply to an owner of property who builds or imprevathereon,and OCCCROUP RFS.UNITS
who doessuch work himself or through his own employees,provided that such _
imprwemenle are not Intended oroffemd forsale.If,however thebullding m TOTAL:
improvementissold withlnoneyearofcomplelbn,theowner-builderwill have
thp,Jlurden of proving that he did not build or improve for purpose ofsaje.). QTy. PLUMBING PERMIT FEE FLOODZONE APN
"I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Profeseloro Code:
The Contractor's License Law don not apply to an owner of property who ALTER-DRAIN A VENT-WATER[EA)
builds or imp.thereon,and who contracts for such p,ojem with a FEE SUMMARY
15aorfQ licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE m exempt under Sec. B k P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N•
. Owner Date - RFLEI'1'11
WORKMAN COMPENSATION DECLARATION ENTITIES PER TRAP SCI TAX Y_ N_
❑I he affirm that I have a certificate of consent to self-insure,or a RECEIPT#
certificate ofWorkers'Compewtionlrmunsmora certified copythereof(Sec. GAS EA.SYSIPM-I WCAOUTLETS PARK FEE Y N
3800.Lab CJ p RECEIPT x
Policy# GAS F.A.SYSTEM-OVER 4(EA)
Com BUILDING DIVISION FEES
�CertBledm V(tied
city —� CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
Certified mpybfikd wllhthe city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-gAM.I•ARY-S10RM FA pB6•I• Date Recei t#
(Thissection need not be completed dthe permit b toren hundred dollars
($IM)orl..)' - WATER HEATER W/VENT/ELFGTR ENERGY FEE Y - N
I certify that In the performance of the work for which this permit is Issued,
I shall not employ any person in any manner so u to become subject to the WATERSYSDM/TREATING
Workere Compensation Lawsof California.Date PAID
TW
Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Revel f#
Z O NOTICE TO APPLICANT.If,after making this Certilla =
le of Eaen,you
should become subject to the Werkers'Compensation provbiom of the Labor TOTAL: al�
LA Cie,you must forthwith comply with such provisions orlhb permit shall be U LCs/
W `> deemed revoked.
CLC CONSTRUCTION LENDING AGENCY SEISMIC FEE SO
I hercbyafBrm that there V a construction fending agency for the perform 'TOTAL: ELECTRIC FEE
7 Z anm ofthe workfor which this permit is Issued(Sec.3097,CIv.C.)
V O (.ended Name 41.1rA114!_ PLUMBING FEE
LL F- Undoes Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1 cartitylhat I haveread thbappliatlonand staothatthe above information
1 bcomvt.I agreeto comply with all city and countyoadinanaea and Mate jaws PERMIT ISSUANCE FEES PAID:
>. relating to building comtmctlon,and hereby authorize representatives alibis -
N city to enter upon the above-crentloned property for Inspection purposes. ALTERORADDTOMECFL
Z (We)agree to save,i°demWfy an d keep harming the City of Cupertino Date Reeelpt#
V against liabilities,Odgmants,coke and expenses which may In any way ague AIR HANDLING UNIT fro 10,000 CFM) SUBTOTAL'
gat t said City In consequence OW
e�quence of the granting of this permit
y �7uM�+�i 7— S- 96 AIR HANDLING UNIT(OVER IO, CFM) CONSTRUCTION TAX
U�
Sig reef Applicant/Contractor / Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or bund le hazardous HEATING UNIT(TO 100,ODO BTU)
mbl Date Recei t#
ateras defined by the Cupertino Municipal Code,Chapter 9.17,and the `
1 Lealth and Safety Code Section 25532(x)? HEATING UNIT(OVER 100,000 BTU) TOTAL: l SU
n Yee M No I
p
Will the applicant or future bu ilding occupant use equipment or d evims VENTILATION FAN(SINGLE RESID) IS AW&DATE
which emit hazardous air coma minants as defined by the Bay Area Air t
. lity Management District? BOILER-COMP 0HPOR 100,000 BT1n �''�t,t ",
Yea ❑No l
i have read thehaaarclouematerials requirements under Chapter6.95 of BOLLER.COMP(OVER 100,000 BTU)
the California Health A Sn(ety Code,Sections,25505,25533 and 2SS34.1
understand that if the building dog not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. CittJ r.f ("i^MfIrIA
responsibility to notify the occupant of the requirements which muse be met
Cod
ois Iguana a fkate of Occupancy.
C
For authorimd 4eck Data ISSUED BY:',Vb�"�•'1"`
TOTAL:
OFFICE COPY