20191 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project IdentificationPERMIT NO.
BUBritn Adams: 20191
an
nem it,. U CITY OF CUPERTINO-BUILDING DIVISION
Contnclois Name: Lk.No:' APPLICATION / PERMIT `l
, V BUR.DINGELECTRICALPLUM1'PING-MECHANICAL CATEGORY CONTROL N Q
ArehltM/ELco; ngineer Lie.Na Cl
uR QTY ELECTRIC'PERMIT FEE BUILDING PERMIT INFO
Address: ". RTUS C,l4 A 503 o FFIMITISSUANCE "'zBLUU U� -
- LICENSED CONTRACTOR'S DECLARATION - I�.1
I hereby affirm that l am Bceneet under provisions or ChaPrer9(commen APPLIANCESRESIDENML
JOB DFSCRIRION
Ing with SeNan7arocandeffect ofihe Bustuwand Pro(naloneCnde,and my /���,
license is in fuH fame and dfect. pie r��111r�11® • /^-'t///QJ�
License Clav LIeN eZ '. 3k, �� -ADD �r
Date Contractor UP TO 2DO ANTS
ARCHITECTS DECLARATION 201-1000 AMPS
977 I understand my pleushal be used u public recomda OVERIODOAMPS SQ.FT.FLOOR AREA $/SQ.FT.
Llmosed Professional SIGNSELECTRICAL D �.
�6 OWNER-BUILDER DECLARATION SP[CIALCItCIRT/M '-\ �• �,a �x4,<7. 2
Zy, 'b I hereby affIrmthat l sort exempt foam the Contractor's License Law for the 0 /71_!
following mages.(Section 7031.5,Business and Pro(eaens Code:Any city or "71
O TEMP.METER OR I'OL ST.
r4 cmntywhichrequlmsapermltmmmtmaalteclmpro ,de=n h,orrepair 69q 1P
h`s.r O�
yy any etndureprbrtoib bwance,alwrequlresthe appllcantfm such Termite Rp g // / eg J ''MM oa-ti
m file a signed statement that he b Rmnsed pursuant to the provisions of the RWCES l5
3µ Contractor'sLkenselawtChapter9(mmmenctngwlthSection 7000)ofDivi- SWIMMING L'ELE_ Qr
�OS slon 3afthe Business and Pro(mC
loru ode)orthat het,exempithere(romand _ A TI N •V
the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWf HESFTXfI1RFS ��
sits appllesnt fora permit subjects the applicant too civil penalty ofnot nn than �r N
five hundred dollars(SW. 1'+ 'ay• /.\
nl, NEW RESIbENTIAL ELECTR- ' ]TI'. STORIES ECONSTRUCTION
comp
-as owner of the Property,or le employes with wages r t it ��
70 sale tloMwRldothe work and lhestu urebno mended or o(fc dfor -,
O sok(Sec.7044,Business and Professions Code:The Contractor's Lice Law I
�R does not apply to an owner of property who Wilds or improves the anQ ` /9 t `� OCG GROfJI' '-RES[NITS
who doessuchwork himself orthrough his own employes,provided at -crJmr ,�._
Improvements are out intended oraffered for mate.It however,thebulidi TOTAL:
ImproveZe tib ldwithinoneyearofcompleioa theowner-buBderwg/ ve
lwm
tttQarcien of proving that he did not Wild or Improve for Pur'�Meo( J. PLUMBING PERMIT FEE FLOOD ZANE APN
U Las owner of the property,am exclusively contracting�It need PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business am Profesalme Code:
The Contractors License law don one apply t......r of property who pLTFR-DRAIN h VEM- A builds or Improves thereon,and who contracts for such P4ojeats with a
co�d.(s)Iftemad Pursuant to the Contractors License Law. x- FEE SUMMARY
u'am exempt under Sec B k P C for this reason BACKFLOW TFW D COUTSIDE FEES
DRAINS Roo 'A CONTI. SANITARY Y N_
\ wnee Date RECEIVE#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y_ N_
• VI hereby a/firm that I have a certlfkate of consent to seH-Insure,or a ` x� RECEIVE N
eferti(leste ofWorken'Compar Honlmunnceoracertlfbd mpythereo((Sec. s�t�
3800,lab CJ G •1 ING40I1TLETS 2�s•YJ PARK FEE AECEIVEN
I Eaury# - G F:A.SYSCFM-0VEA4(EA)
Co eey BUILDING DIVISION FEES
�CertiOed copy b herebyfurnished.the city GREASE/MDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
�CertlOed copy b filed with the Aly inspection dividers.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID IMA3
COMPENSATION INSURANCE SEWER-SANITARY-SITIRM EA 200FC Date RCYeI [#
(This section need not be completed If the permit b foron hundred dollars
IS)OD)or leas.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N b,0a
I certify that ot the performance or the work for which this permit b Issued, l
I shall not employ any n n N any manner n as to become subject to the WATER SYSTEM/TREATING ([
O Worlurm Compepsst sof G—WmNa.Date PAID 7
Applicant_ s1 p, B• r. Date Remi [#
Z NOTICETO L .AN ,.Nerovddz this Cmtif1cam.f Ex.mppdtu u
should bees subject to the Wmixos'COmpensalion provblanoftha7. s TOTAL:
N
Code,you=at forthwith comply with such provision.,this permit scc N`a� ys t BUILDING FEE ��l C
a'
j deemed rooked.
LU CONSTRUCTION LENDING AGENCY o SEISMIC FEE
Il Iherebyafflrmthat there b a construction lending agency for the perform-
V Q Under's Name T /1 ELECTRIC FEE12
Z ance ofthe work which his permit b Wued(Sec.3097,Cw.C.) Y TOTAL: t
PLUMBING FEE
Lamers Add MECHANICAL PERMIT FEE
O W Icuttlythat l hawmad thb ...m satethatlhe above Information �9rryy�6 MEGHANICAL'FEE
6 ismrreatlagreetocomply with all city and county ordinancesand gate laws PERMIT ISSUANCE �W' FEES FAIR:
T relatingtobuildingmmutructlon,Orad henbyauthotesrepneentativcao(this ^ p�
F N city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADDED MECH. 4�
Z (We)agree to save,indemnllyan d keep harmless the City of Cupertino Date Receipt#
()
against liablBtles,ls cab,costa and expenn which may In anywayaccrue AIR HANDLING UNIT(TO 10,ODO CFM) SUBTOTAL:
against aald y ro equenceof the gra ntingdthbpermlt.
,1(' AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX
IV. Signatur9bfAppucant/Contnclor Date ECIIAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE -
Willtheapplicantorfuture building occupant store or handle hazardous HEATING UNIT CM 100,000 BT() Date Retel t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I lealth and Safety Code Section 25532(x)? HEATING UNIT(OVER 100,000 BM - TOTAL: t
❑Yes No
Will the applies rat Mrs building oro pant use equipment or device VENTILATION FAN(SINGLE RESID) L ISSLJ�)UaA')E
which coot haea rdous air contaminants as defined by the Bay Area Air
Qua lily Management District? BOILER-COMP OHP OR 100,000 BTU)
�_I Yea QNo
I Ihave read the hazarTicus materials requitmeenb under Chapter 6.95 of BOILER-COMP(OVER 100,(X0 BTU)• r J�1R� 1 Fq
s 1990
l the Ca lifornix Health A Safety Code,Section 25505,25533 and 25534.1
lundent.ad that if the building does not currently have a tenant,that It ismy NEW RESIDENTIALMECH. SQE7
responsibility to notify the occupant of the requirements which most be met CI y__
elortobsuaneso(a CediHesteo(Ocmpancy. L L,I F{IJII#
V `
Owner oraulhorlud agent .Date bSgpEpgy. � 6 arcV`L
TOTAL:
OFFICE COPY